The nurse is providing care for a patient with an external fixation for a fracture involving severe bone damage. What is the priority of care?

Monitoring pin and wound sites for signs of infection.

Being aware that the patient may experience issues with body image.

Helping the patient achieve a desired level of mobility.

Providing a caring and supportive attitude during a challenging time.

Answer and Explanation

The Correct Answer is A

A. Monitoring pin and wound sites for signs of infection. Correct. Infection at the pin and wound sites is a major risk with external fixation and requires vigilant monitoring and care.

B. Being aware that the patient may experience issues with body image. While body image concerns are important, they are not the primary priority in care.

C. Helping the patient achieve a desired level of mobility. Mobility is important, but the primary concern with external fixation is preventing and managing infections.

D. Providing a caring and supportive attitude during a challenging time. While providing emotional support is important, it is not the primary priority of care for external fixation.

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

Explanation

A. Check the client's toes for color, temperature, and sensation. This assessment ensures that there is no neurovascular compromise, which is crucial for detecting complications like compartment syndrome.

B. Elevate the client's foot. Elevation reduces swelling and helps decrease pain and inflammation.

C. Apply a compression bandage or ace wrap to the client's ankle. Compression helps reduce swelling and provides support to the injured area.

D. Encourage range of motion of the client's foot and ankle. Encouraging range of motion immediately after an acute injury can exacerbate pain and swelling. Immobilization and rest are initially required.

E. Apply heat to the client's ankle. Heat should not be applied in the acute phase as it can increase swelling and inflammation. Cold therapy is recommended initially.

A. Increased red blood cell count B. Decreased lymphocyte count C. Decreased body temperature D. Absent left pedal pulse

Correct Answer is D

Explanation

A. Increased red blood cell count: An increased red blood cell count is not an immediate concern in the context of a fracture.

B. Decreased lymphocyte count: A decreased lymphocyte count could indicate an infection or immune issue but is not the immediate priority in a fracture situation.

C. Decreased body temperature: Hypothermia can be concerning, but in the context of a fracture, it is not as critical as neurovascular compromise.

D. Absent left pedal pulse: An absent pedal pulse indicates a possible compromised circulation to the lower extremity, which is a critical and immediate concern. It could signify a compartment syndrome or arterial damage requiring urgent intervention.

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The nurse is providing care for a patient with an external fixation for a fracture involving severe bone damage. What is the priority of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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