The nurse is caring for a patient with an external fixation device. Which of the following actions should the nurse implement? Select all that apply.

Clean pins with hydrogen peroxide four times daily.

Monitor pin sites at least daily.

Loosen screws holding the pins during cleaning.

Use strict aseptic technique for pin care.

Follow agency protocol for pin care.

Avoid touching the pins.

Answer and Explanation

Correct Answer : B,D,E

A. Clean pins with hydrogen peroxide four times daily. Hydrogen peroxide is not recommended for routine pin care as it can damage tissue and delay healing. Overuse can also lead to the formation of oxygen bubbles in the tissue, which may cause complications. Recommended cleaning solutions often include saline or a mild antiseptic, depending on the facility's protocol.
B. Monitor pin sites at least daily: Regular monitoring of pin sites is essential to detect early signs of infection or complications such as redness, swelling, warmth, or discharge. Early detection allows for prompt intervention, which is crucial in preventing more severe infections and complications.
C. Loosen screws holding the pins during cleaning. Loosening screws can destabilize the fixation device and disrupt the bone alignment, potentially causing injury and delaying healing. Screws and pins should remain securely tightened unless adjustments are being made by a qualified healthcare provider.
D. Use strict aseptic technique for pin care: Using strict aseptic technique helps prevent the introduction of microorganisms at the pin sites. This is critical because external fixation devices create a direct pathway for pathogens to enter the body, which can lead to serious infections like osteomyelitis.
E. Follow agency protocol for pin care: Each healthcare facility may have specific protocols and guidelines for pin care based on evidence-based practices. Following these protocols ensures that the care provided is consistent and meets the latest standards for infection control and patient safety.
F. Avoid touching the pins. While it is crucial to avoid unnecessary handling of pins to prevent contamination, touching the pins during necessary cleaning and care using aseptic technique is allowed. Completely avoiding touching the pins could result in inadequate cleaning and care.

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Correct Answer is C

Explanation

A. You can start taking sildenafil (Viagra): this should fix the problem.: This is inappropriate advice for the nurse to give. The use of medications like sildenafil should be discussed with the physician, especially considering potential interactions with hypertension medications.
B. This is a normal side effect of the medication and you will get used to it.: While erectile dysfunction can be a side effect of hypertension medications, telling the patient they will "get used to it" is dismissive and not supportive.
C. I will talk to your doctor to see if adjustments can be made.: This is appropriate as it acknowledges the patient's concern and involves the healthcare provider to explore potential medication adjustments or alternatives.
D. You should stop taking this medication immediately.: This is incorrect and potentially dangerous. Stopping hypertension medication abruptly can lead to uncontrolled blood pressure and other serious issues.

A. Provide names of support groups. B. Schedule an annual physical examination. C. Refer the patient to a free clinic. D. Refer the patient for financial assistance.

Correct Answer is C

Explanation

A. Provide names of support groups: While support groups can offer emotional and educational support, they do not address the immediate financial barrier to obtaining necessary medications.
B. Schedule an annual physical examination: Regular check-ups are important, but they do not directly address the issue of medication affordability and access to care.
C. Refer the patient to a free clinic: Free clinics often provide low-cost or no-cost medications and healthcare services, which can help the patient access the necessary treatments and follow-up care.
D. Refer the patient for financial assistance: Financial assistance programs can be helpful, but they might take time to apply and be approved. Immediate referral to a free clinic can provide more immediate support.

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The nurse is caring for a patient with an external fixation device. Which of the following actions should the nurse implement? Select all that apply.

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Correct Answer is C

Explanation

Correct Answer is C

Explanation

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