A nurse is assessing a client who has a pressure injury. Which of the following findings should the nurse expect as an indication the wound is healing?

A. Encouraging the client to urinate every 2 hr is not appropriate in this situation because the client is receiving continuous bladder irrigation (CBI), and the urinary catheter is meant to drain continuously. The issue is likely related to a blockage or clot in the catheter, not the need for the client to urinate.

B. Securing the urinary catheter to the upper left quadrant is not appropriate because the catheter should be positioned properly to allow for proper drainage. Securing it in an inappropriate location could cause kinks or obstructions.

C. Using 0.9% sodium chloride to perform an intermittent bladder irrigation is the correct action. The client’s scant amount of fluid and bladder spasms suggest that the catheter may be blocked, likely by a clot. Performing an intermittent irrigation with saline can help clear any obstructions in the catheter and restore proper drainage.

D. Applying a cold compress to the suprapubic area is not appropriate for treating bladder spasms caused by a potential obstruction. The priority action is to clear the catheter and ensure proper drainage.

A. While the Morse Fall Risk scale is important for assessing fall risk, it is not the priority after an ORIF procedure. The client’s neurovascular status should be closely monitored to prevent complications.

B. A neurovascular assessment is the priority after an ORIF of the femur. This includes checking for circulation, sensation, and movement (CSM) in the affected leg to ensure there is no compromise to the blood flow or nerve function. This is crucial to detect complications like compartment syndrome or circulatory impairment early.

C. The Braden scale is used to assess the risk for pressure ulcers and is important but not the priority after surgery. Neurovascular status takes precedence in the postoperative period.

D. Pain assessment is important for managing the client’s comfort, but it is secondary to ensuring proper neurovascular function to prevent further complications such as ischemia or nerve damage.