Question

A client is in skeletal traction. With the nurse's assessment, it is noted that the pins appear red, swollen, and there is purulent drainage. What action does the nurse take first?

a) Notify the physician immediately
b) Clean the site with antiseptic solution
c) Continue monitoring without intervention
d) Document the findings in the patient's chart

Answer 1

The first action the nurse should take is to notify the physician immediately when pins in skeletal traction appear red, swollen, and show purulent drainage, indicating a potential infection.

Step-by-step explanation:

If a client in skeletal traction has pins that are red, swollen, and showing purulent drainage, the nurse's first action should be to notify the physician immediately. These symptoms indicate a possible infection that could worsen without prompt and appropriate treatment. The nurse should then document the findings in the patient's chart, which is also a crucial step but follows notifying the physician. Cleaning the site with an antiseptic solution may be necessary, but it is not the first action to take before consulting with the physician on the appropriate protocol. Continuing to monitor without intervention is not appropriate in the face of signs of infection, as it could lead to serious complications for the patient.