A nurse is assisting in the plan of care for a client who has constipation after receiving opioid medication for incisional pain. Which of the following actions should the nurse take first?

is not the correct answer because the tricuspid area is not the location where a nurse should auscultate for a murmur related to mitral valve regurgitation. The tricuspid area is located at the fifth intercostal space at the lower left sternal border, and is the site where blood flows from the right atrium to the right ventricle during systole.<\/p>"},"B":{"choice":"-","reason":"

The correct answer is choice B, the mitral area. When auscultating for a murmur in a client with mitral valve regurgitation, the nurse should place the stethoscope at the mitral area, which is the fifth intercostal space at the left midclavicular line. This is because the mitral valve is located at this spot and is the site where blood flows from the left atrium to the left ventricle during systole.<\/p>"},"C":{"choice":"-","reason":"

is not the correct answer because the aortic area is not the location where a nurse should auscultate for a murmur related to mitral valve regurgitation. The aortic area is found at the second intercostal space at the right sternal border, and is the site where blood flows from the left ventricle to the aorta during systole.
\r\nChoiceD4 is not the correct answer because the pulmonic area is not the location where a nurse should auscultate for a murmur related to mitral valve regurgitation. The pulmonic area is located at the second intercostal space at the
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\r\nleft sternal border, and is the site where blood flows from the right ventricle to the pulmonary artery during systole.<\/p>"},"D":{"choice":"-","reason":"

The correct answer is choice B, the mitral area. When auscultating for a murmur in a client with mitral valve regurgitation, the nurse should place the stethoscope at the mitral area, which is the fifth intercostal space at the left midclavicular line. This is because the mitral valve is located at this spot and is the site where blood flows from the left atrium to the left ventricle during systole.<\/p>"}}

The correct answer is Choice C.

Choice A rationale: Applying traction weight to the external fixator is not recommended, as it can cause excessive stress on the pins and wires, leading to complications such as infection, loosening, or breakage1.Traction is usually applied to skeletal pins that are inserted into the bone without an external frame2.

Choice B rationale: Monitoring the neurovascular status of the affected limb is important, but every 8 hours is not frequent enough.The nurse should perform neurovascular checks every 2 to 4 hours for the first 24 hours, then every 4 to 8 hours, according to the facility policy3. This is to assess for signs of nerve damage, compartment syndrome, or impaired circulation, which can result from the injury or the device.

Choice C rationale: Administering pain medication 30 min prior to pin care is a correct intervention, as it can help reduce the discomfort and anxiety associated with the procedure. Pin care involves cleaning the pin sites with an antiseptic solution and applying sterile dressings to prevent infection and promote healing. The frequency and technique of pin care may vary depending on the type of device, the condition of the wound, and the facility protocol.

Choice D rationale: Adjusting the clamps on the device’s frame daily is not a nursing intervention, as it can alter the alignment and stability of the fracture. The clamps should be tightened only by the orthopedic surgeon or a trained technician, and only when necessary. The nurse should inspect the device for any loose or broken parts and report any problems to the surgeon.

So, the correct answer is Choice C, after analysing all choices.