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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Hypertension and headache are not typical signs of hypermagnesemia. These symptoms are more commonly associated with conditions like hypertension or intracranial pressure.
B. Tachycardia and tachypnea are not characteristic of hypermagnesemia. In fact, hypermagnesemia typically causes bradycardia and hypoventilation due to the depressant effect of magnesium on the cardiovascular and respiratory systems.
C. Depressed deep tendon reflexes are a classic sign of hypermagnesemia. Magnesium sulfate acts as a central nervous system depressant, and elevated magnesium levels can impair neuromuscular function, leading to reduced reflexes.
D. Positive Trousseau's sign is indicative of hypocalcemia, not hypermagnesemia. It is a sign of low calcium levels, where a blood pressure cuff inflated above systolic pressure for 3 minutes causes muscle spasms in the hand and forearm.

A. This fluid is most compatible with antibiotics B. This fluid acts as free water to help dilute the sodium. C. This fluid contains higher than normal amounts of sodium. D. This fluid is used to pull water out of the interstitial space.

Correct Answer is B

Explanation

A. DSW (Dextrose in water) is not specifically used for compatibility with antibiotics. It is an intravenous fluid that provides water and glucose, but its use is not based on antibiotic compatibility.
B. DSW (5% dextrose in water) provides free water to the body. In the case of acute dehydration and hypernatremia, the water helps to dilute the high sodium levels in the bloodstream, lowering the sodium concentration.
C. DSW does not contain higher-than-normal amounts of sodium. It contains only a small amount of sodium from the dextrose, and its primary role is to provide free water.
D. DSW is not used to pull water out of the interstitial space. Hypertonic solutions (like 3% saline) are used for that purpose, not DSW.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client receiving an infusion of IV magnesium sulfate. Which of the following findings would indicate to the nurse that the client is experiencing hypermagnesemia?

Correct Answer is C

Explanation

The nurse is caring for a client who is admitted with acute dehydration and a serum sodium level of 151mEq/L. The nurse is anticipating the administration of DSW based on which of the following principles?

Correct Answer is B

Explanation

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