A nurse plans care for a client who has an external fixator on the lower leg. Which intervention would the nurse include in the plan of care to decrease the client’s risk for infection?

Washing the frame of the fixator once a day.

Releasing fixator tension for 30 minutes twice a day.

Avoiding moving the extremity by holding the fixator.

Scheduling for pin care to be provided every shift.

Answer and Explanation

The Correct Answer is D

Choice A reason: Washing the fixator frame may maintain hygiene but does not directly address the primary infection risk at pin sites, where skin breaks allow bacterial entry. Pin sites are more critical, as infections like osteomyelitis can develop from poor pin care.
Choice B reason: Releasing fixator tension disrupts the device’s stability, risking bone misalignment and delayed healing. It does not reduce infection risk and may increase tissue trauma, potentially creating more entry points for bacteria at the pin sites.
Choice C reason: Avoiding movement by holding the fixator prevents normal joint mobility, risking stiffness, but does not address infection risk. Pin sites remain the primary infection source, as bacteria can enter through skin breaks, requiring specific cleaning protocols.
Choice D reason: Regular pin care (every shift) with sterile technique (e.g., chlorhexidine) removes debris and bacteria from pin sites, reducing the risk of osteomyelitis. External fixators penetrate skin, creating infection-prone areas, making frequent, meticulous pin care the most effective intervention to prevent infection.

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Correct Answer is D

Explanation

Choice A reason: Notifying the doctor before taking other medications is correct, as phenytoin interacts with many drugs (e.g., warfarin) via liver enzyme induction (CYP450), altering drug levels. This shows understanding of the need to prevent adverse interactions.
Choice B reason: Scheduling a dental appointment is appropriate, as phenytoin causes gingival hyperplasia due to fibroblast proliferation. Regular dental care prevents gum overgrowth complications, indicating the client understands this side effect and its management.
Choice C reason: Not switching phenytoin brands is correct, as different formulations may have varying bioavailability, affecting seizure control. Consistent branding ensures stable drug levels, reflecting the client’s understanding of maintaining therapeutic efficacy.
Choice D reason: Stating a desire to stop phenytoin suggests a misunderstanding, as seizures often require lifelong antiepileptic therapy to prevent recurrence. Abrupt cessation can cause rebound seizures due to unopposed neuronal excitability, indicating a need for further education.

A. Positioning the child with hips flexed 90 degrees at all times. B. Keeping the weights in contact with the floor. C. Checking for skin irritation from traction equipment. D. Releasing the weights on a schedule.

Correct Answer is C

Explanation

Choice A reason: Positioning with hips flexed at 90 degrees is inappropriate for Buck’s traction, which is a skin traction applied to the lower leg to align fractures. Excessive hip flexion can disrupt traction alignment and increase discomfort or complications.
Choice B reason: Weights in Buck’s traction must hang freely to maintain constant force for fracture alignment. Contact with the floor negates the traction’s effect, risking bone misalignment and delayed healing, making this an incorrect care practice.
Choice C reason: Checking for skin irritation is critical in Buck’s traction, as prolonged pressure from straps or bandages can cause pressure ulcers or skin breakdown. Regular skin assessment ensures early detection and prevention of complications, maintaining the traction’s safety and efficacy.
Choice D reason: Releasing weights disrupts the continuous force needed for fracture alignment in Buck’s traction. This can lead to bone displacement, increased pain, or delayed healing, making scheduled weight release an inappropriate and harmful practice.

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A nurse plans care for a client who has an external fixator on the lower leg. Which intervention would the nurse include in the plan of care to decrease the client’s risk for infection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Which of the following statements by the client indicates a need for further teaching?

Correct Answer is D

Explanation

What will the nurse include when caring for a child in Buck’s extension?

Correct Answer is C

Explanation

The nurse assesses a client with rheumatoid arthritis (RA) and Sjögren syndrome. What assessment would be most important for this client?

What will the nurse teach parents when giving instructions for acute conjunctivitis?

After teaching a client with a fractured humerus, the nurse assesses the client’s understanding. Which dietary choice demonstrates that the client correctly understands the nutrition needed to assist in healing the fracture?

The recommended safe dosage of erythromycin for a child is 20 mg/kg/day in four equal doses. The child weighs 33 lb. The medication is supplied in 125 mg/mL. What is the safe and therapeutic dosage for this child?

What would the nurse include when creating a teaching plan that includes the long-term administration of phenytoin (Dilantin)?

An adolescent has just had a generalized seizure and collapsed in the school nurse’s office. When should the nurse call 911?

A nurse is teaching a client with multiple sclerosis who is prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol). Which statement should the nurse include in this client’s discharge teaching?

On entering the room of a child in Buck’s traction, the nurse makes all of the following observations. Which observation requires a nursing intervention?