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 C
Explanation
Choice A reason: Anticonvulsants are medications used to prevent seizures. While seizures can occur after a stroke, anticonvulsants are not routinely prescribed unless the patient has a history of seizures or has experienced seizures post-stroke. Therefore, anticonvulsants would not be the standard pharmacologic therapy for all patients being discharged after an ischemic stroke.
Choice B reason: Diuretics are used to remove excess fluid from the body and are commonly prescribed for conditions such as heart failure or high blood pressure. They are not typically used as a standard treatment for ischemic stroke unless the patient has a specific condition that requires fluid management.
Choice C reason: Antithrombotic agents, such as aspirin or clopidogrel, are commonly prescribed to patients after an ischemic stroke to prevent further clot formation and reduce the risk of recurrent strokes. These medications work by inhibiting platelet aggregation and are a key part of secondary prevention in stroke management.
Choice D reason: Opioid analgesics are strong painkillers that are used to treat severe pain. They are not typically prescribed upon discharge for ischemic stroke patients unless there is a specific indication for pain management that cannot be managed with other medications.
Correct Answer is D
Explanation
Choice A reason: A client with diabetes mellitus presenting with acute ketoacidosis does not necessarily require a private room unless there are other infection control concerns. Acute ketoacidosis is a metabolic complication of diabetes that can be managed in a general ward setting with appropriate medical care and monitoring.
Choice B reason: An older adult client admitted with aspiration pneumonia would benefit from a private room if the pneumonia is caused by an infectious agent that requires droplet or airborne precautions. However, aspiration pneumonia is often a result of inhaling food, stomach acid, or saliva into the lungs, and not always infectious.
Choice C reason: A client with a compound fracture of the right femur would require a private room if there is an associated risk of infection due to the open nature of the injury. However, standard precautions and wound care can often be managed in a semi-private or general ward setting unless there are specific infection control issues.
Choice D reason: A client reporting fever, night sweats, and cough for 2 days may be exhibiting symptoms of a communicable disease such as tuberculosis. This client would require a private room with airborne precautions to prevent the spread of infection to other patients and healthcare workers.
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