In performing a focused assessment, the practical nurse (PN) lifts the client's skin as seen in the photo. Which should the PN do next?

A. Respiratory rate 18 breaths/minute
The respiratory rate is within the normal range for an adult (12-20 breaths/minute). No immediate follow-up is required for this vital sign.
B. Heart rate 101 beats/minute
An elevated heart rate (tachycardia) can indicate several issues, including fever, infection, or pain. In the context of a surgical site infection and elevated temperature, tachycardia is a sign of systemic response and needs to be evaluated further to determine the cause and appropriate intervention.
C. Capillary refill 2 seconds
Capillary refill time of 2 seconds is within the normal range (≤ 2 seconds) and indicates adequate perfusion. No immediate follow-up is needed.
D. Breath sounds clear and equal bilaterally
This finding indicates no acute respiratory issues. No immediate follow-up is necessary based on this assessment.
E. Turban dressing is saturated with serosanguinous drainage
Saturation of the dressing with serosanguinous drainage indicates a significant amount of wound drainage, which could suggest worsening of the infection or a new complication. This finding requires immediate follow-up to assess the wound and determine if additional interventions or changes in treatment are necessary.
F. Blood pressure 140/84 mm Hg
While slightly elevated, this blood pressure reading is not excessively abnormal and does not require immediate follow-up in the absence of other symptoms. Monitoring is required but not urgent.
G. Temperature 101.9° F (38.8° C)
An elevated temperature indicates a fever, which is a sign of infection. Given the positive MRSA culture and the need for infection control, this temperature warrants immediate follow-up to assess for worsening infection and determine the need for antipyretics or antibiotics.
H. Client is awake and alert
Being awake and alert is a positive finding and does not require immediate follow-up

• Medication dose: 30 mg enoxaparin
• Medication concentration: 30 mg per 0.3 mL (prefilled syringe)
• Frequency: Every 12 hours
• Duration: 10 days

Calculation:

1. Injections per day: Since the medication is given every 12 hours, the client will receive injections 2 times per day (24 hours / 12 hours/injection).
2. Total medication per day: To find the total amount of enoxaparin needed per day, multiply the single injection dose by the number of injections:

Total enoxaparin/day = Dose per injection x Number of injections/day = 30 mg/injection x 2 injections/day = 60 mg/day

1. Volume of medication per day: Now, we need to find the volume of solution needed to deliver the total daily dose (60 mg) based on the medication concentration (30 mg/0.3 mL). We can achieve this with a proportion:

Volume (mL) / Total dose (mg) = Concentration (mg/mL)

Volume (mL) = (Total dose (mg) x Concentration (mL/mg)) / Concentration (mg/mL)

Plugging in the values:

Volume (mL) = (60 mg x 0.3 mL/mg) / 30 mg/mL

Volume (mL) = 18 mL / 30 mL/mL

Simplifying:

Volume (mL) = 0.6 mL

Therefore, the practical nurse (PN) should administer 0.6 mL of enoxaparin each day.