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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Generalized abdominal pain - Abdominal pain may be present in peritonitis, but it can develop after other signs and symptoms.
Choice B Reason:
Increased heart rate - An increased heart rate can be a response to infection, but it is not the earliest indicator of peritonitis.
Choice C Reason:
Fever - Fever can also be a sign of infection and peritonitis but may not be the earliest manifestation in all cases.
Choice D Reason:
Cloudy effluent
The earliest indication of peritonitis in a client undergoing peritoneal dialysis is often the presence of cloudy or turbid peritoneal dialysis effluent (fluid). Cloudy effluent can indicate the presence of infection or inflammation in the peritoneal cavity, which is a significant concern in peritoneal dialysis. It's crucial for clients and their partners to recognize this early sign and seek medical attention promptly.
Correct Answer is B
Explanation
Choice A Reason:
Gently massage the area around the client's incision is not recommendable. Massage may not be suitable for a recently operated area and could potentially worsen pain and disrupt the healing process.
Choice B Reason:
Apply an ice pack to the client's knee is recommendable. Applying an ice pack to the client's knee can help reduce pain and inflammation following a total knee arthroplasty. Ice can help numb the area and reduce swelling, providing relief to the client's discomfort. It's important to use a barrier, such as a cloth or towel, between the ice pack and the skin to prevent frostbite.
Choice C Reason:
Perform range-of-motion exercises to the client's knee is not recommendable. Range-of-motion exercises may be beneficial for recovery, but they might not be appropriate at this pain level. Pain should be managed before engaging in such activities.
Choice D Reason:
Place pillows under the client's knee is recommendable. Elevating the knee might help with comfort, but addressing the pain directly should be the priority.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today