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
The oral mucosa is the most reliable indicator of central cyanosis because it reflects the oxygenation of central tissues. When there is a lack of oxygen in the bloodstream, the lips and mucous membranes, such as the oral mucosa, appear blue or cyanotic. This is a clear sign that the central tissues are not receiving adequate oxygenation.
Choice B rationale
The sclera of the eye is not a reliable indicator of central cyanosis. The sclera is white and does not change color due to oxygen levels. Instead, it may become yellow in jaundice or red in inflammation but does not reflect central cyanosis.
Choice C rationale
The ear lobes are peripheral areas and do not reliably indicate central cyanosis. Peripheral cyanosis can occur due to local blood flow issues, and ear lobes can appear blue in cold conditions even when central oxygenation is normal.
Choice D rationale
The soles of the feet, similar to the ear lobes, are peripheral areas and not reliable indicators of central cyanosis. Cyanosis in the feet can result from poor peripheral circulation rather than central hypoxia.
Correct Answer is C
Explanation
Choice A rationale
Hypokalemia is a potential concern with diuretic therapy, but not with hypertonic saline solution (3% NaCl) administration for hyponatremia.
Choice B rationale
Hypovolemia is less likely to occur with hypertonic saline infusion. The main concern is overcorrection leading to fluid overload.
Choice C rationale
Fluid overload is a significant risk when administering hypertonic saline (3% NaCl). Nurses should closely monitor for signs of fluid overload, such as edema, crackles in the lungs, and increased blood pressure.
Choice D rationale
Hypernatremia is a possible complication of hypertonic saline administration, but it is not as immediate a concern as fluid overload. Monitoring for fluid overload should take precedence.
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