A nurse is caring for a client who is 6 hr. postoperative following application of an external fixator for a tibial fracture. Which of the following actions should the nurse take?
Palpate the dorsalis pedis pulse.
Adjust the clamps on the fixator frame.
Wrap sterile gauze on the sharp point of the pins.
Maintain the affected extremity in a dependent position
The Correct Answer is A
Choice A reason:
Palpating the dorsalis pedis pulse is the appropriate option. Checking the dorsalis pedis pulse is crucial to assess the perfusion and circulation to the affected extremity. This is an important nursing action to monitor the patient's vascular status and ensure that there is adequate blood flow to the extremity distal to the fixator. A decrease or absence of the dorsalis pedis pulse could indicate potential circulation issues and require immediate attention.
Choice B reason:
Adjusting the clamps on the fixator frame is incorrect. The nurse should not adjust the clamps without specific orders from the healthcare provider. The external fixator is typically secured according to the surgeon's specifications, and any adjustments should be made under the guidance of the surgical team.
Choice C reason:
Wrapping sterile gauze on the sharp point of the pins is incorrect. The sharp pins used in an external fixator are an integral part of the device and are placed to stabilize the fracture. They should not be covered with sterile gauze, as this could interfere with their function and increase the risk of infection.
Choice D reason:
Maintaining the affected extremity in a dependent position is incorrect. Keeping the affected extremity in a dependent position (lower than the heart) can increase swelling and impair circulation. After surgery and fixation, it's often recommended to elevate the extremity to reduce swelling and promote proper circulation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Confirming the correct position of the line by obtaining a blood sample is appropriate. Inserting a central venous catheter is a procedure that involves placing a catheter into a large vein, typically in the neck, chest, or groin. Confirming the correct placement is crucial to prevent complications such as pneumothorax (lung collapse) or catheter misplacement.
Choice B reason:
Instructing the client to cough as the catheter is inserted is not a standard practice during central venous catheter insertion and could lead to unnecessary complications.
Choice C reason:
Placing the head of the client's bed lower than the foot (Trendelenburg position) is not a standard practice during central venous catheter insertion and would not be helpful for this procedure.
Choice D reason:
Cleansing the site with hydrogen peroxide is not the recommended method for central venous catheter insertion. Typically, a sterile technique and appropriate antiseptic solution are used to reduce the risk of infection.
Correct Answer is D
Explanation
Choice A reason:
"use my heating pad on a low setting to keep my feet warm". This statement is incorrect. Using a heating pad, especially on a low setting, is not recommended for individuals with PAD. It can lead to burns or skin damage due to reduced sensation in the feet.
Choice B reason:
"rest in my recliner with my feet elevated for about an hour every afternoon" This statement is incorrect. While elevating the feet can help with blood circulation, it's important to avoid prolonged periods of inactivity. Regular physical activity is important for improving circulation.
Choice C reason:
"soak my feet in hot water before trimming my toenails". This statement is incorrect. Soaking feet in hot water can cause burns or damage to the skin for individuals with reduced sensation due to PAD. Trimming toenails should be done carefully and without soaking to prevent injury and infection.
Choice D reason:
"apply a lubricating lotion to the cracked areas on the soles of my feet every morning “This statement is correct. Clients with peripheral arterial disease (PAD) are at risk of reduced blood circulation to the extremities, including the feet. Proper foot care is crucial to prevent complications such as non-healing wounds or infections. Applying a lubricating lotion to cracked areas can help keep the skin moisturized and prevent further complications.
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