A patient with an abrasion covered by a bandage reports increased drainage and irritation at the site. What should the nurse do first?

A. Increase the frequency of wound dressing changes:This is an appropriate measure to manage exudate and clean the wound, but it is not the highest priority action for treating the underlying infection.

B. Initiate contact isolation precautions:This is necessary if the organism requires isolation (e.g., MRSA), but it is a safety measure, not the clinical priority for treating the patient's infection.

C. Apply a non-adherent dressing:This is an appropriate dressing choice for a healing wound, but the priority is treating the infection itself.

D. Administer prescribed antibiotics:An infected Stage 3 pressure ulcer (confirmed or highly suspected) requires systemic treatment. Administering the prescribed antibiotic is the most critical intervention to prevent the localized infection from escalating to a systemic infection (sepsis) and to eliminate the bacteria that are stalling the healing process.

A. Instruct the patient to avoid using the injured limb: This is part of the treatment (Rest) but is an intervention, not the most appropriate immediate step for assessing the severity of the injury.

B. Assess for pain and swelling at the injury site: A contusion involves damaged capillaries, leading to bleeding into the tissues, which causes the bluish discoloration, swelling, and pain. The most appropriate immediate nursing assessment involves checking for the extent of swelling, which can indicate underlying hematoma formation, and the level of pain, which guides the need for further diagnostics (like an X-ray to rule out fracture) or pain management.

C. Administer analgesics without further assessment: Pain is a crucial indicator of injury severity. Administering medication before a proper assessment can mask symptoms of a more serious, underlying injury (like a fracture or compartment syndrome).

D. Apply a warm compress to the area immediately: For acute contusions, cold therapy (ice) is used initially to cause vasoconstriction, which helps limit bleeding, decrease swelling, and reduce pain. A warm compress would promote vasodilation, potentially increasing the bleeding and swelling.