The nurse is caring for a patient who has a pelvic fracture and an external fixation device.
How should the nurse perform assessment of pressure areas and provide skin care to the patient's back and sacrum?
Have the patient lift the back and buttocks using a trapeze.
Ask the patient to turn to the side independently.
Roll the patient over to the side by pushing on the patient's hip.
Defer back assessment until the patient is ambulatory.
The Correct Answer is A
Choice A rationale
Having the patient lift their back and buttocks using a trapeze allows for proper assessment of pressure areas and skin care. This technique reduces the risk of further injury or discomfort and provides better access for the nurse to assess the skin condition.
Choice B rationale
Asking the patient to turn to the side independently may not be feasible for a patient with a pelvic fracture. This method can cause pain and risk further injury, making it an unsuitable choice for assessing pressure areas.
Choice C rationale
Rolling the patient over to the side by pushing on the patient's hip is not recommended as it can exacerbate the injury and cause pain. This method is not appropriate for patients with pelvic fractures.
Choice D rationale
Deferring back assessment until the patient is ambulatory is not a safe practice. Pressure areas should be regularly assessed to prevent skin breakdown and complications, even if the patient is not yet ambulatory.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Administering a prescribed bronchodilator medication is the priority action for a patient experiencing an acute asthma attack. This helps to open the airways and improve breathing.
Choice B rationale
While checking the patient's vital signs is important, it is not the first action in the acute management of an asthma attack. The immediate priority is to relieve bronchospasm.
Choice C rationale
Collecting a sputum sample for analysis is not the first priority in an acute asthma attack. Stabilizing the patient's breathing is more urgent.
Choice D rationale
Obtaining a detailed health history is essential for comprehensive care but is not the first action during an acute asthma attack. Rapid intervention to improve breathing is the priority.
Correct Answer is C
Explanation
Choice C rationale
Administering another nitroglycerin tablet is appropriate if the client's chest pain has not been fully relieved after the initial dose. Nitroglycerin helps to dilate blood vessels, improving blood flow to the heart and relieving angina. A second dose can be given if the pain persists, following the protocol for managing chest pain.
Choice A rationale
Obtaining an ECG is important for diagnosing and monitoring cardiac conditions; however, in this immediate context, further pain relief takes precedence. After ensuring pain relief, an ECG can be performed to assess the client's cardiac status.
Choice B rationale
Calling the Rapid Response Team is unnecessary if the client’s chest pain severity has already decreased. The priority should be to continue managing the chest pain with additional nitroglycerin if needed and monitoring the client's response.
Choice D rationale
Initiating a peripheral IV might be required for administering medications or fluids, but it is not the immediate action needed in this scenario. The priority is to provide additional pain relief with nitroglycerin.
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