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 B
Explanation
Choice A reason : Desmopressin is a medication used to treat conditions like diabetes insipidus and certain cases of hemophilia, not allergic reactions such as hives and urticaria.
Choice B reason: Diphenhydramine is an antihistamine that is commonly used to treat allergic reactions, including hives and urticaria. It works by blocking the action of histamine, a substance in the body that causes allergic symptoms.
Choice C reason: Spironolactone is a diuretic and is not used to treat allergic reactions. It is typically prescribed for conditions like heart failure, hypertension, and certain hormonal disorders.
Choice D reason: Metoclopramide is a medication used to treat nausea and gastroparesis, not allergic reactions.
Correct Answer is ["8.3"]
Explanation
Step 1: Total volume = 1000 mL (which is 1 liter)
Step 2: Total time = 2 hours. But since the infusion pump rate is typically set in mL per minute, we need to convert this to minutes. There are 60 minutes in an hour, so 2 hours is 2 × 60 = 120 minutes.
Step 3: Now we can calculate the rate. The rate is the total volume divided by the total time. So, the rate = 1000 mL ÷ 120 minutes.
Calculating the above gives us the rate at which the nurse will set the infusion pump. Let's calculate it:
Step 4: Rate = 1000 mL ÷ 120 minutes = 8.33 mL/minute.
So, the nurse will set the infusion pump at a rate of approximately 8.33 mL per minute. If rounding is required, this can be rounded to 8.3 mL per minute.
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