The nurse is assessing a child who has a fractured bone that has ...

[lak]

The nurse is assessing a child who has a fractured bone that has been pinned. There is caked blood and some purulent drainage in the pin area. Which of the following would be the best action for the nurse to take?
 
  a. Clean the pin area with hydrogen peroxide solution.
  b. Clean the area with soap and water.
  c. Use hospital policy and, if not available, use alcohol on sterile 4  4's to clean the pin.
  d. Report findings, and obtain a physician's order for pin-cleaning procedure.

Question 2

The nurse using the Hirschberg test would expect to find which of the following in a child with normal eyes?
 
  a. the light reflected symmetrically in the center of both corneas
  b. the light reflecting red on the optic nerve
  c. arteries and veins in the proper proportion
  d. no evidence of retinal detachment

[kkenney]

Answer to Question 1

D

Feedback
A Incorrect. Hydrogen peroxide solution is not an effective cleaning agent for the pin area for adults. Further studies need to be conducted to determine the best cleaning agent for children. Therefore, this would not be the best action for the nurse to take. The nurse's findings indicate an infection and should be reported first.
B Incorrect. There is insufficient evidence on which to recommend any single method of pin care. The nurse's findings indicate an infection and should be reported first.
C Incorrect. There is insufficient evidence on which to recommend any single method of pin care. The nurse's findings indicate an infection and should be reported first.
D Correct. The best action for the nurse to take after finding caked blood and some purulent drainage in the pin area is to report the findings, and obtain a physician's order for pin-cleaning procedure. Purulent drainage, redness, swelling, elevated temperature, odor, and complaints of pain are signs of infection.

Answer to Question 2

A

Feedback
A Correct. The nurse using the Hirschberg test would expect to find the light reflected symmetrically in the center of both corneas in a child with normal eyes.
B Incorrect. The nurse using the Hirschberg test would not expect to find the light reflecting red on the optic nerve.
C Incorrect. The nurse using the Hirschberg test would not be checking for arteries and veins in the proper proportion.
D Incorrect. The nurse using the Hirschberg test would not be checking for retinal detachment.

[lak]

TYSM

[rachel]

Excellent