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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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.

A. Place the client in a protective environment. B. Obtain a stool specimen with gloves. C. Clean surfaces with chlorhexidine. D. Wash hands with alcohol-based hand rub

Correct Answer is B

Explanation

Choice A Reason:

Placing the client in a protective environment is not necessary for C. difficile gastroenteritis. Standard precautions, including diligent hand hygiene and appropriate personal protective equipment, are sufficient.

Choice B Reason:

Obtain a stool specimen with gloves is necessary. Obtaining a stool specimen with gloves is an appropriate nursing action when caring for a client with Clostridium difficile (C. difficile) gastroenteritis. C. difficile is a bacterium that can cause diarrhea and other gastrointestinal symptoms. It's important to follow infection control practices to prevent the spread of the bacteria.

Choice C Reason:

Cleaning surfaces with chlorhexidine is not the preferred disinfectant for C. difficile. Sporicidal agents, such as bleach-based solutions, are recommended to effectively kill the spores of C. difficile.

Choice D Reason:

Washing hands with alcohol-based hand rub is not sufficient for C. difficile. C. difficile spores are resistant to alcohol-based hand sanitizers, so using soap and water for handwashing is recommended to ensure proper removal of the spores.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication?

Correct Answer is D

Explanation

A nurse is planning care for a client who has Clostridium difficile gastroenteritis. Which of the following is an appropriate nursing action?

Correct Answer is B

Explanation

A nurse is caring for a client who is scheduled for a mastectomy. The client tells the nurse. "I'm not sure I want to have a mastectomy." Which of the following statements should the nurse make?

A nurse is assessing a client who has a pressure ulcer. Which of the following findings should the nurse expect as an indication the wound is healing?

A nurse is reviewing the medical record of a client who is scheduled for a CT scan with contrast media. Which of the following medications should the nurse instruct the client to withhold for 48 hr. following the procedure?

A nurse in a long-term care facility is caring for a bedridden client. Which of the following findings should alert the nurse to a potential complication of the client's immobility?

A nurse is caring for a client who is experiencing an acute asthma attack. Which of the following should the nurse identify as a contributing factor to the client's manifestations?

A nurse is caring for a client who has tuberculosis and is taking rifampin. The client reports that her saliva has turned red-orange in color. Which of the following responses should the nurse make?

A nurse on an oncology unit is caring for a client who is receiving internal radiation therapy. Which of the following actions should the nurse take?

A home health nurse is assessing the home environment of a client who has cystic fibrosis. Which of the following equipment should the nurse plan to recommend?