The nurse is caring for a client with external fixation of the tibia. Which of the following would the nurse include in the plan of care?
Removing and applying the fixator for showers.
Documenting pin site assessment and care.
Encouraging the patient to lie prone several times per day.
Turning the patient every 3 hours.
The Correct Answer is B
A. Removing and applying the fixator for showers is not appropriate. The external fixator should not be removed by the nurse without proper medical guidance. Showers should be managed in a way that prevents the fixator from becoming wet or contaminated.
B. Documenting pin site assessment and care is essential for clients with external fixation. The nurse should regularly assess pin sites for signs of infection (e.g., redness, swelling, drainage) and ensure proper care is provided to prevent complications.
C. Encouraging the patient to lie prone several times per day may not be necessary or appropriate unless specifically ordered by the provider. The patient’s positioning should be based on comfort and the provider’s instructions to avoid strain on the injured limb.
D. Turning the patient every 3 hours is a general nursing practice for preventing pressure ulcers, but it is not specific to the care of a client with external fixation. The focus should be on protecting the fixator and ensuring the limb is properly supported.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A client with heart failure and crackles in the lungs is more likely to have fluid volume excess rather than deficit.
B. A client with renal failure and pitting edema is typically at risk for fluid retention and overload, not deficit.
C. Being NPO for 4 hours is unlikely to cause significant fluid volume deficit, as this is a short period without oral intake.
D. A client with Crohn's disease experiencing diarrhea is losing significant fluids and electrolytes, placing them at high risk for fluid volume deficit. Diarrhea is a common cause of dehydration and requires close monitoring.
Correct Answer is B
Explanation
A. While having the son verify understanding may seem appropriate, using a family member as a translator is not acceptable for informed consent due to the potential for miscommunication or bias.
B. Contacting the hospital translator ensures accurate and professional communication. A certified translator is required for legal and ethical reasons to ensure the patient fully understands the procedure, risks, and benefits.
C. Using the son to clarify questions may lead to inaccuracies or incomplete understanding. Professional translation services must be utilized in medical settings.
D. The son does not need to sign the consent form. The provider must ensure the patient understands the procedure, and the consent form is signed by the patient or their legal representative after professional translation.
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