The nurse is performing pin care for a patient with an external fixation device for a fractured tibia. Which assessment finding by the nurse should be reported to the unit care coordinator?
Areas around pins are dry.
Crusts around pins.
Purulent drainage around pins.
Absence of pain at the site.
The Correct Answer is C
Choice A reason: Dry areas around the pins can be a normal finding if the pin sites are healing properly. It indicates that there is no excessive moisture that could promote bacterial growth and infection. However, the nurse should continue to monitor for any signs of redness, swelling, or pain that could indicate a developing infection.
Choice B reason: Crusts around the pins are typically a sign of dried exudate, which can be part of the normal healing process. The crusts should be monitored and cleaned according to the healthcare facility's protocol to prevent infection. If the crusts are accompanied by other signs of infection, such as redness, warmth, or purulent drainage, they should be reported to the healthcare provider.
Choice C reason: Purulent drainage around the pins is a sign of infection and should be reported immediately to the unit care coordinator. Infections at pin sites can lead to complications such as osteomyelitis, delayed healing, or even systemic infection. Prompt intervention with appropriate cleaning and possibly antibiotics is necessary to prevent further complications.
Choice D reason: The absence of pain at the site can be a normal finding and is not typically a cause for concern unless there is an expectation of pain based on the patient's condition or recent procedures. However, a complete lack of sensation could indicate nerve damage or other issues, so the nurse should assess for other signs of neurovascular compromise and report any concerns to the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason : Uric acid levels are expected to be increased in a client with acute gout. Gout is associated with hyperuricemia, where serum or plasma urate concentrations exceed 6.8 mg/dL. This elevation in uric acid can lead to the formation of monosodium urate crystals in joints, causing the characteristic painful inflammation of gout.
Choice B reason : Intrinsic factor is not related to gout. It is a protein produced by the stomach that is necessary for the absorption of vitamin B12.
Choice C reason : Chloride levels are typically not affected in acute gout and are not a specific indicator for this condition.
Choice D reason : Creatinine kinase is an enzyme found in the heart, brain, skeletal muscle, and other tissues. Elevated levels may indicate muscle damage but are not a specific marker for gout.
Correct Answer is B
Explanation
Choice A reason: Glucose Dextrose Oral (GDO) is not typically used in the immediate management of anaphylactic shock. Anaphylaxis requires rapid treatment to address severe allergic reactions and GDO does not play a role in this emergency situation.
Choice B reason: Epinephrine (Adrenaline) is the first-line treatment for anaphylactic shock. It works quickly to improve breathing, stimulate the heart, raise a dropping blood pressure, reverse hives, and reduce swelling of the face, lips, and throat.
Choice C reason: Dexamethasone (Decadron) is a corticosteroid that may be used in the treatment of anaphylaxis to reduce inflammation. However, it is not the first medication administered due to its slower onset of action compared to epinephrine.
Choice D reason: 0.9% Normal Saline is used for intravenous fluid resuscitation in anaphylactic shock but is secondary to the administration of epinephrine. It helps to maintain blood pressure and is important in the overall management but not the first medication given.
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