What should the nurse assess for in a patient with an open fracture?
Joint range of motion
Neurological function in the unaffected limb
Signs of infection at the fracture site
Quality of pain experienced by the patient
The Correct Answer is C
In a patient with an open fracture (compound fracture), there is a risk of infection due to the exposure of the bone to the external environment. The nurse should assess for signs of infection, such as redness, warmth, swelling, drainage, and increased pain at the fracture site.
a. Assessing joint range of motion is important, but it is not the priority in a patient with an open fracture, where preventing infection is the main concern.
b. Assessing neurological function in the unaffected limb is not directly related to the open fracture and may not be the priority at this time.
d. Assessing the quality of pain experienced by the patient is important for pain management but is not the priority over assessing for signs of infection in an open fracture.
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Correct Answer is A
Explanation
An open fracture, also known as a compound fracture, occurs when the bone penetrates the skin and is exposed to the external environment. It carries a higher risk of infection due to the exposure of the bone to external contaminants.
b. Closed fracture: A closed fracture, also known as a simple fracture, does not break the skin, and the bone remains enclosed within the body.
c. Impacted fracture: An impacted fracture occurs when the bone ends are forced into each other, commonly seen in long bones such as the femur. It does not involve the bone penetrating the skin.
d. Stress fracture: A stress fracture is a tiny crack in the bone caused by repetitive stress and overuse. It does not involve the bone penetrating the skin.
Correct Answer is B
Explanation
It is crucial for the patient to regularly check for signs of skin irritation and redness around the cast edges. Skin irritation and redness can indicate pressure points or infection, and early identification can prevent complications.
a. Breaking off rough edges of the cast with scissors can damage the cast and compromise its structural integrity. The patient should not alter the cast in any way.
c. Using lotion to moisturize the skin under the cast is not recommended, as it can lead to skin irritation and may compromise the cast's fit and function. The skin under the cast should be kept dry and clean.
d. Using a heating pad to alleviate discomfort is not recommended, as excessive heat can lead to skin irritation and may weaken the cast. The patient should use ice packs or follow the healthcare provider's instructions for pain management.
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