Solution Manual For Foundations and Adult Health Nursing, 8th Edition

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Cooper and Gosnell: Foundations and Adult Health Nursing, 8th EditionChapter07:Asepsis and Infection ControlAnswer Keys-Critical Thinking QuestionsNursing Care Plan7-1:The Patient with anInfection1.Mr.R.has a peripheral IV infusing andreportsdiscomfort at the site of insertion. Whatshouldthe nursedo?The nurse should immediately assess the IV site for obviousdislodgment of the IV catheter,edema, erythema,or increased warmth orcoolness. Coolness may indicate IVinfiltration; theother signs may indicate irritation (possiblyfrom a previously administered medication or as anadverse effect of it) or infection.In general,if an IV site is obviously infiltrated, nursingjudgment is sufficient todeterminewhether to stopthe IV infusionand/or remove the infiltrated IV catheter.Warm compresses maygenerally be applied per nursingjudgment as well. (Facility policies must be verified.)Thehealth care providermust be notified sothatthe determinationcan be made regarding thenecessity to restart a newintravenous access site.2.Mr.R.has a urinary catheter connected to continuousdrainage. Hereportsburning at the siteof insertionandthe nursenotesdark, concentrated urine in the tubing. Whatshould the nurse donext?The nurse should assess the site of the catheter insertionfor any signs ofedema, erythema, orexudate. The nurseshould then take the patient’s vital signs, notingany changes in temperatureand pulse. Compare thedata obtained withpatient’s previousvital signs.??Following these nursing actions, the nurse shouldobtain urine samples for urinalysis and cultureandsensitivity (using aseptic technique), in anticipation of thehealth care provider’s orders tocome.All of the above should then be reported to thepatient’shealth care provideras promptly aspossible. The nurseshould also encouragethe patient to increase his fluidintake. Makeadditional fluids available to him, if notcontraindicated.3.The nursenoteson the sheet of laboratoryresults forMr.R.that hisWBCcountis 2800/mm3.Why is thisa concern,and whatis recommended as a precautionary measure?This indicates a severely compromised immune system,placing the patient at very high risk forinfection. Thepatient is especially susceptible to microorganisms thatnormally do not pose asignificant threat to a healthyimmune system. A healthy immune system will destroy or

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Foundations And Adult Health Nursin...

Solution Manual For Foundations and Adult Health Nursing, 8th Edition

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