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 D
Explanation
Choice A rationale
A complete blood count (CBC) can provide general information about the body's response to an MI, such as white blood cell count, but it is not definitive for diagnosing an MI.
Choice B rationale
A lipid profile measures cholesterol levels and helps assess cardiovascular risk, but it is not useful for diagnosing an acute MI.
Choice C rationale
An electrocardiogram (ECG) is essential for diagnosing an MI as it shows the heart's electrical activity and can indicate ischemia or infarction.
Choice D rationale
Troponin levels are the most specific and sensitive markers for myocardial infarction. Elevated troponin levels confirm heart muscle damage due to an MI, making it the definitive test.
Correct Answer is B
Explanation
Choice B rationale
Potassium levels should be reviewed before administering furosemide. Furosemide is a loop diuretic that can cause significant potassium loss through increased urine output. Monitoring potassium is crucial to prevent hypokalemia, which can lead to cardiac arrhythmias and other serious complications.
Choice A rationale
Bicarbonate levels are not directly impacted by furosemide use and are less critical to review in this context. While they are important in assessing acid-base balance, they are not the primary concern when administering furosemide.
Choice C rationale
Phosphate levels are not typically affected by furosemide and are not the main focus before administration. Monitoring phosphate might be important in other scenarios, but it is not directly relevant here.
Choice D rationale
Carbon dioxide levels are more relevant to respiratory function and acid-base balance but are not directly impacted by furosemide. The focus should be on monitoring electrolytes, particularly potassium, to prevent complications from diuretic therapy.
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