ANSWER KEY FOR CASE STUDIES CHAPTER 7-56
ANSWER KEY Cooper: Foundations and Adult Health Nursing, 9th Edition CHAPTER 07 Nursing Care Plan 7-1: The Patient with an Infection 1. Mr. R. has a peripheral IV infusing and reports discomfort at the site of insertion. What
should the nurse do? The nurse should immediately assess the IV site for obvious dislodgment of the IV catheter, edema, erythema, or increased warmth or coolness. Coolness may indicate IV infiltration; the other signs may indicate irritation (possibly from a previously administered medication or as an adverse effect of it) or infection. In general, if an IV site is obviously infiltrated, nursing judgment is sufficient to determine whether to stop the IV infusion and/or remove the infiltrated IV catheter. Warm compresses may generally be applied per nursing judgment as well. (Facility policies must be verified.) The health care provider must be notified so that the determination can be made regarding the necessity to restart a new intravenous access site. 2. Mr. R. has a urinary catheter connected to continuous drainage. He reports burning at
the site of insertion and the nurse notes dark, concentrated urine in the tubing. What should the nurse do next? The nurse should assess the site of the catheter insertion for any signs of edema, erythema, or exudate. The nurse should then take the patient’s vital signs, noting any changes in temperature and pulse. Compare the data obtained with patient’s previous vital signs. Following these nursing actions, the nurse should obtain urine samples for urinalysis and culture and sensitivity (using aseptic technique), in anticipation of the health care provider’s orders to come. All of the above should then be reported to the patient’s health care provider as promptly as possible. The nurse should also encourage the patient to increase his fluid intake. Make additional fluids available to him, if not contraindicated. 3. The nurse notes on the sheet of laboratory results for the patient that his WBC count is 2800/mm3. Why is this a concern, and what is recommended as a precautionary TEACH Answer Key Cooper: Foundations and Adult Health Nursing, 9th Edition Copyright © 2023 by Elsevier Inc. All rights reserved.