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 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.
Correct Answer is C
Explanation
A. This statement is incorrect. Lispro is a rapid-acting insulin, and its duration of action is much shorter than 24 hours. It is typically effective for about 3-5 hours.
B. Administering Lispro 60 minutes before meals would be too early, as it peaks in about 1-2 hours after injection and works best when given closer to meal times.
C. Lispro should be administered 15-30 minutes before meals to match the onset of action, which begins within 15 minutes of injection. This timing allows the insulin to be active when blood glucose rises after eating.
D. Lispro does not require administration 2-6 hours before meals, as this would not align with its rapid onset of action.
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