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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","C","D"]

Explanation

A. Paresthesia: Numbness or tingling sensations (paresthesia) can occur due to decreased blood supply and nerve function.
B. Pruritus: Itching (pruritus) is not typically associated with arterial occlusion. It is more often related to skin conditions or allergies.
C. Pain: Pain is a hallmark symptom of arterial occlusion, often described as severe and sudden, due to tissue ischemia.
D. Pallor: Affected limbs or areas may appear pale (pallor) because of reduced blood flow.
E. Palpitations: Palpitations are not a direct symptom of arterial occlusion. They are more related to cardiac conditions.

A. Obtain an electrocardiogram (ECG) exam B. Obtain intravenous access C. Administer 2 L of oxygen per nasal cannula D. Obtain a rectal temperature

Correct Answer is C

Explanation

A. Obtain an electrocardiogram (ECG) exam: While an ECG is important to assess cardiac status, it is not the immediate priority compared to addressing the low oxygen saturation.
B. Obtain intravenous access: IV access is important for administering medications and fluids but does not take precedence over addressing hypoxia.
C. Administer 2 L of oxygen per nasal cannula: This is correct. The priority is to improve oxygenation since hypoxia can exacerbate neurological damage in a stroke patient. An SpO2 of 88% is low and requires immediate correction to prevent further complications.
D. Obtain a rectal temperature: Temperature assessment is not as urgent as addressing the immediate need for oxygen to improve SpO2 levels.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following are clinical manifestations of arterial occlusion? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

The nurse assists with care of a confused patient who presents to the emergency department with stroke symptoms. Vital signs are blood pressure 174/100 mm Hg. pulse 64 beats per minute, and SpO2 88% on room air. Which nursing intervention is priority?

Correct Answer is C

Explanation

The nurse is caring for Mr. Able, age 46, who has gout. Which of these morning laboratory values does the nurse monitor for this patient?

The nurse is contributing to the plan of care for a patient who has a traumatic finger amputation. What should the nurse consider?

The nurse is caring for a patient with a blunt trauma and tissue injury to the lower extremity. Which signs could develop in a patient with compartment syndrome?

The nurse is caring for a patient with a fracture. Which complications should the nurse monitor for? Select all that apply.

The nurse is caring for a patient with a transverse fracture. Which are goals for managing patient care? Select all that apply.

A patient asks the nurse how to prevent a stroke. Which statement by the nurse is correct? Select all that apply.

Which risk factors would be considered modifiable in the prevention of stroke? Select all that apply.

The nurse is reinforcing teaching about dietary changes with a patient newly diagnosed with hypertension. What should the nurse include in the teaching about a DASH diet? Select all that apply. (Select All that Apply.)