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 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.
Correct Answer is B
Explanation
Choice A rationale
A complete blood count (CBC) can provide information about the client's overall health and presence of infection, but it does not specifically address the potential underlying cause related to the urinary system.
Choice B rationale
Urinalysis with culture is the most relevant diagnostic test for evaluating the underlying cause of fever, chills, and severe left costovertebral pain. These symptoms suggest a possible urinary tract infection or pyelonephritis, which can be confirmed with urinalysis and culture.
Choice C rationale
A chest X-ray would not be the priority in this scenario as the symptoms suggest a urinary tract issue rather than a respiratory problem. A chest X-ray is more useful for assessing lung conditions.
Choice D rationale
A CT scan of the abdomen and pelvis can be helpful in evaluating the extent of a urinary tract infection or identifying other causes of abdominal pain, but it is typically not the first-line diagnostic test. Urinalysis with culture is more specific for identifying urinary infections. .
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