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 C
Explanation
Choice A reason: Digoxin is primarily used to treat atrial fibrillation and heart failure. It is not the first-line medication for sinus bradycardia with ST-segment elevation, as it can further slow down the heart rate.
Choice B reason: Sotalol is a beta-blocker and an antiarrhythmic medication that can be used to treat ventricular arrhythmias and maintain sinus rhythm in atrial fibrillation. However, it is not indicated for sinus bradycardia and could exacerbate the condition.
Choice C reason: Atropine is the medication of choice for symptomatic sinus bradycardia. It works by blocking the action of the vagus nerve on the heart, leading to an increased heart rate. Atropine can quickly reverse the symptoms of bradycardia, such as dizziness and shortness of breath.
Choice D reason: Lidocaine is an antiarrhythmic medication used to treat ventricular arrhythmias. While it can be used in acute settings, it is not the first choice for sinus bradycardia with ST-segment elevation.
Correct Answer is B
Explanation
Choice A reason : Administering corticosteroids is not the first-line action for dyspnea related to fluid overload or other causes of respiratory distress in this context.
Choice B reason : Slowing the infusion rate is appropriate when there are signs of fluid overload, such as dyspnea and hypertension. Contacting the provider is crucial for further assessment and management, which may include diuretics or other interventions.
Choice C reason : Lowering the head of the bed to semi-Fowler's may provide some relief for dyspnea, but it does not address the potential cause, which in this case could be fluid overload.
Choice D reason : Changing the infusion to lactated Ringer's would not be appropriate if the client is experiencing symptoms of fluid overload. The type of fluid is less important than the volume and rate of administration in this scenario.
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