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: This statement does not indicate a need for further instruction. It is recommended to take other medications at least 30 minutes after alendronate to ensure proper absorption of the drug.
Choice B reason: This statement indicates a need for further instruction. Alendronate should be taken with plain water, not milk. The calcium in milk can interfere with the absorption of alendronate.
Choice C reason: This statement is correct and does not indicate a need for further instruction. Patients are advised to stay upright for at least 30 minutes after taking alendronate to prevent esophageal irritation or reflux.
Choice D reason: This statement is correct and does not indicate a need for further instruction. Periodic bone density tests are necessary to monitor the effectiveness of alendronate therapy in treating osteoporosis.
Correct Answer is C
Explanation
Choice A reason : A blood pressure of 138/76 mm Hg is within the higher range of normal and is not typically considered an adverse effect of metoprolol, which is used to lower blood pressure.
Choice B reason : A temperature of 36.3°C (97.3°F) is within the normal range and is not an adverse effect of metoprolol.
Choice C reason : A heart rate of 48/min is considered bradycardia and can be an adverse effect of metoprolol, which is a beta-blocker that can slow down the heart rate.
Choice D reason : A respiratory rate of 10/min is on the lower end of the normal range but is not a typical adverse effect of metoprolol. However, if the patient shows signs of respiratory distress, it should be addressed.
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