The nurse is caring for a patient with an external fixation device. Which of the following actions should the nurse implement? Select all that apply.

Clean pins with hydrogen peroxide four times daily.

Monitor pin sites at least daily.

Loosen screws holding the pins during cleaning.

Use strict aseptic technique for pin care.

Follow agency protocol for pin care.

Avoid touching the pins.

Answer and Explanation

Correct Answer : B,D,E

A. Clean pins with hydrogen peroxide four times daily. Hydrogen peroxide is not recommended for routine pin care as it can damage tissue and delay healing. Overuse can also lead to the formation of oxygen bubbles in the tissue, which may cause complications. Recommended cleaning solutions often include saline or a mild antiseptic, depending on the facility's protocol.
B. Monitor pin sites at least daily: Regular monitoring of pin sites is essential to detect early signs of infection or complications such as redness, swelling, warmth, or discharge. Early detection allows for prompt intervention, which is crucial in preventing more severe infections and complications.
C. Loosen screws holding the pins during cleaning. Loosening screws can destabilize the fixation device and disrupt the bone alignment, potentially causing injury and delaying healing. Screws and pins should remain securely tightened unless adjustments are being made by a qualified healthcare provider.
D. Use strict aseptic technique for pin care: Using strict aseptic technique helps prevent the introduction of microorganisms at the pin sites. This is critical because external fixation devices create a direct pathway for pathogens to enter the body, which can lead to serious infections like osteomyelitis.
E. Follow agency protocol for pin care: Each healthcare facility may have specific protocols and guidelines for pin care based on evidence-based practices. Following these protocols ensures that the care provided is consistent and meets the latest standards for infection control and patient safety.
F. Avoid touching the pins. While it is crucial to avoid unnecessary handling of pins to prevent contamination, touching the pins during necessary cleaning and care using aseptic technique is allowed. Completely avoiding touching the pins could result in inadequate cleaning and care.

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Correct Answer is D

Explanation

A. Women often have vague symptoms of stroke such as weakness or hallucinations: While women may sometimes present with less typical symptoms, stating that hallucinations are common is misleading. Stroke symptoms in women can vary, but weakness and other neurological deficits are more common.
B. The FAST acronym stands for Face, Arms, Swallowing, and Time: This is incorrect. FAST stands for Face (drooping), Arms (weakness), Speech (difficulty), and Time (importance of quick action).
C. Stroke patients always present with dysphasia: This is incorrect. Not all stroke patients have speech difficulties; symptoms vary depending on the area of the brain affected.
D. Treatment that begins within 3 hours of symptom onset can minimize or avoid permanent loss of function: This is correct. Timely intervention, especially with treatments like tPA for ischemic strokes, can significantly reduce the extent of brain damage and improve outcomes.

A. Diabetes mellitus B. Calcium deficiency C. Peripheral vascular problems in both legs D. An acute obstruction in the vessels of the legs

Correct Answer is C

Explanation

A. Diabetes mellitus: While diabetes can cause peripheral vascular disease, it alone does not specifically cause intermittent claudication (pain on exertion relieved by rest).
B. Calcium deficiency: Calcium deficiency is not typically associated with intermittent claudication or peripheral vascular symptoms.
C. Peripheral vascular problems in both legs: This is correct. The symptoms described are classic for intermittent claudication, which is commonly due to peripheral arterial disease (PAD). PAD causes pain due to reduced blood flow to the muscles during exertion, which is relieved by rest.
D. An acute obstruction in the vessels of the legs: Acute obstruction would likely cause more severe and persistent symptoms, such as acute pain and loss of pulses, not just pain with walking.

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The nurse is caring for a patient with an external fixation device. Which of the following actions should the nurse implement? Select all that apply.

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Naxlex Comprehensive Predictor Exams

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