A client is in skeletal traction. With the nurse's assessment, it is noted that the pins appear red, swollen, and there is purulent drainage. What action does the nurse take first?

Choice A reason: Creating a susceptible host is not a way to break the chain of infection, but rather a way to facilitate it. A susceptible host is someone who is vulnerable to infection due to factors such as age, immunocompromised status, or chronic diseases.

Choice B reason: Maintaining the integrity of a portal of entry is a way to break the chain of infection, because it prevents the entry of microorganisms into the body. A portal of entry is any place where microorganisms can enter the body, such as the skin, mucous membranes, or respiratory tract. By reducing skin breakdown, the nurse is protecting the skin from becoming a portal of entry for infection.

Choice C reason: Creating a reservoir to decrease the risk of infection is a contradiction, because a reservoir is a place where microorganisms can multiply and survive, such as a human, animal, or environment. A reservoir increases the risk of infection, not decreases it.

Choice D reason: Sterilizing the area to reduce the reservoir risk is a way to break the chain of infection, but it is not related to reducing skin breakdown. Sterilizing the area means killing or removing all microorganisms from a surface or object, such as a surgical instrument or a wound dressing. This can reduce the reservoir risk, but it does not affect the integrity of the skin as a portal of entry.

Choice A reason: Cleansing the skin around the pins is the action that the nurse takes first, because it is the most urgent and relevant action. Cleansing the skin around the pins is a procedure that involves removing any dirt, debris, or secretions from the pin sites, which can help prevent or treat infection, inflammation, or pain. Cleansing the skin around the pins is a priority intervention, as it can reduce the risk of complications, such as osteomyelitis, sepsis, or pin loosening.

Choice B reason: Collecting a culture of the purulent fluid is not the action that the nurse takes first, because it is not the most urgent and relevant action. Collecting a culture of the purulent fluid is a procedure that involves obtaining a sample of the pus from the pin sites and sending it to the laboratory for analysis, which can help identify the type and source of infection. Collecting a culture of the purulent fluid is an important intervention, but it should be done after cleansing the skin around the pins, and with a medical order and a sterile technique.

Choice C reason: Administering an antibiotic is not the action that the nurse takes first, because it is not the most urgent and relevant action. Administering an antibiotic is a procedure that involves giving the client an antimicrobial agent, which can help fight or prevent infection. Administering an antibiotic is an important intervention, but it should be done after cleansing the skin around the pins, and with a medical order and a proper route.

Choice D reason: Instructing the client to complete exercises of the affected extremity is not the action that the nurse takes first, because it is not the most urgent and relevant action. Instructing the client to complete exercises of the affected extremity is a procedure that involves teaching the client how to move and strengthen the muscles and joints of the limb in traction, which can help prevent or treat atrophy, contracture, or thrombosis. Instructing the client to complete exercises of the affected extremity is an important intervention, but it should be done after cleansing the skin around the pins, and with a medical order and a safe technique.