A nurse is assisting in the use of a fracture bedpan for a client who is immobile due to a cast. Which of the following actions should the nurse take?
Hyperextend the client's back while the fracture pan is in place.
Keep the bed flat while the client is on the fracture pan.
Encourage the client to try to defecate for 20 min while on the fracture pan.
Place the shallow end of the fracture pan under the client's buttocks
The Correct Answer is D
A. Hyperextend the client's back while the fracture pan is in place: Hyperextending the client's back is not necessary and can cause discomfort or strain. The client's back should be kept in a neutral position.
B. Keep the bed flat while the client is on the fracture pan: Raising the head of the bed slightly can facilitate the client's positioning and defecation. It is not necessary to keep the bed completely flat.
C. Encourage the client to try to defecate for 20 minutes while on the fracture pan: Encouraging the client to try to defecate for a specific time frame is not necessary and may lead to discomfort or straining. The client should be allowed to take the time they need and not be rushed during this process.
D. Place the shallow end of the fracture pan under the client's buttocks: When using a fracture bedpan, the shallow end should be placed under the client's buttocks to allow for proper positioning. The higher, deeper end of the bedpan is positioned under the client's lower back.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B, C, E, D, A
Explanation
B. Provide adequate lighting to inspect the abdomen: Adequate lighting is important to ensure that the nurse can clearly see and assess the client's abdominal area. This step helps identify any visible abnormalities, such as skin changes, scars, masses, or distention.
C. Listen to the abdominal arteries using the bell of a stethoscope: Listening to the abdominal arteries helps the nurse assess blood flow and detect any abnormal vascular sounds, such as bruits or murmurs. This step provides information about vascular health and potential issues related to blood flow.
E. Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the abdomen: Palpating and locating the liver and spleen borders help assess the size and position of these organs. It can help identify hepatomegaly (enlarged liver) or splenomegaly (enlarged spleen), which could indicate various underlying conditions.
D. Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen: Palpating the abdomen for tenderness helps identify areas of discomfort or pain. It can provide information about potential inflammation, organ enlargement, or other sources of discomfort.
Correct Answer is C
Explanation
Choice A reason:
Documenting the fluid infusion in the client's chart: While documenting the fluid infusion is important, assessing the client's vital signs should take priority to ensure their immediate safety and well-being.
Choice B reason:
Completing an incident report is incorrect Completing an incident report is a necessary step to document the error and initiate appropriate follow-up actions, but it should come after assessing the client's condition.
Choice C reason
Obtaining the client's vital signs is the correct answer. The correct first action for the nurse to take in this situation is to obtain the client's vital signs. Administering an excessive amount of IV fluid could potentially have adverse effects on the client's cardiovascular system, including fluid overload, electrolyte imbalances, and changes in blood pressure. Monitoring the client's vital signs will help assess their current condition and any potential complications resulting from the excess fluid administration.
Choice D reason
Reporting the incident to the unit manager is incorrect. Reporting the incident to the unit manager is important for organizational awareness and accountability, but the nurse's first responsibility is to assess the client's vital signs and address any potential complications.
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