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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Excessive thirst (polydipsia) is a common symptom of hyperglycemia due to dehydration caused by increased urination.
B. Anxiety and tremors are more commonly associated with hypoglycemia (low blood sugar), not hyperglycemia.
C. Excessive urination (polyuria) is a hallmark of hyperglycemia as the body attempts to excrete excess glucose through urine.
D. "Acetone" or "fruity" breath odor is a characteristic sign of diabetic ketoacidosis (DKA), which can occur in severe hyperglycemia.
E. Slow, shallow respirations are not typically associated with hyperglycemia but may occur in cases of respiratory acidosis or DKA, where Kussmaul's breathing (deep, rapid breathing) is more common.
Correct Answer is D
Explanation
A. Dextrose in water is typically used for hydration and to provide some calories. However, this client is presenting with hypotension (BP 88/56), tachycardia (Pulse 110), and weakness, likely due to fluid loss from vomiting. This client needs fluid resuscitation with a solution that will help restore circulating volume, and Dextrose in water does not contain sodium, which is necessary for fluid balance in this case.
B. 6.45% Sodium Chloride is a hypertonic saline solution, which would increase the osmolarity of the blood and pull fluid into the bloodstream. This would not be the first choice for this patient, as it could exacerbate dehydration and electrolyte imbalances.
C. 10% Dextrose in water is also a hypertonic solution that would provide energy but would not adequately address the client's fluid volume deficit or hypotension.
D. 0.9% Sodium Chloride is normal saline, which is an isotonic solution and is the most appropriate choice for fluid resuscitation in this client. It will help restore circulating blood volume, stabilize blood pressure, and provide the necessary hydration to address the client's symptoms of dehydration.
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