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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason:
Attaching the drainage bag to the side rails of the bed can create tension on the catheter and increase the risk of trauma or dislodgment.
Choice B reason:
Emptying the drainage bag when it is three-quarters full is appropriate to prevent the bag from becoming too heavy and pulling on the catheter. However, this is a practice for maintaining bag weight, not part of the overall care plan.
Choice C reason:
Taping the catheter to the lower abdomen is not recommended. Taping the catheter can cause irritation, tension, and skin breakdown, increasing the risk of infection and trauma to the urethra. The catheter should be secured to the thigh using a catheter securement device if necessary.
Choice D reason:
Keeping the drainage bag below the level of the bladder is the correct recommendation. When caring for a client with an indwelling urinary catheter, it is important to maintain proper catheter and drainage bag positioning to prevent complications. Keeping the drainage bag below the level of the bladder helps promote the free flow of urine, prevent reflux of urine into the bladder, and minimize the risk of urinary tract infections.

A. Place the wasted portion of the controlled substance in the sharp container. B. Ask a second nurse to record her signature when wasting any unused portion of the controlled substance. C. Verify the count total of the controlled substance after removing the amount needed. D. Report any discrepancy in the count total of the controlled substance after administration

Correct Answer is D

Explanation

Choice A reason:
Placing the wasted portion of the controlled substance in the sharp container is not correct. Wasted controlled substances should be disposed of according to specific regulations and facility protocols.
Choice B reason:
Asking a second nurse to record her signature when wasting an unused portion of the controlled substance is not a standard practice. The process for wasting controlled substances usually involves following specific documentation procedures, but this does not necessarily require a second nurse's signature.
Choice C reason:
Over-verifying the count total of the controlled substance after removing the amount needed is not a standard practice. It's important to maintain accurate records and documentation, but additional verification of the count total may not be necessary in this context.
Choice D reason:
Reporting any discrepancy in the count total of the controlled substance after administration is the appropriate action. When administering a controlled substance, it is important to accurately account for the medication before and after administration. Any discrepancy in the count of the controlled substance should be reported and documented according to facility policy. This helps ensure proper tracking and accountability of controlled substances, which is crucial for maintaining patient safety and preventing potential diversion or misuse.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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