A nurse is assisting with the care of a client on an orthopedic unit.

Exhibits

Select words from the choices below to fill in each blank in the following sentence.

The client is at risk for developing
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.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C"}

The correct answer is choice A: Fat embolism syndrome.

Choice A rationale:

The client with an open fracture to the right femur is at risk for developing Fat Embolism Syndrome (FES) FES occurs when fat globules from the bone marrow or other tissues enter the bloodstream, leading to systemic complications. In this case, with an open fracture, there is a higher risk of fat emboli entering the circulation. The clinical manifestations of FES include respiratory distress, altered mental status, and petechial rash. These symptoms typically occur within 24-72 hours after the injury, which aligns with the timeline mentioned in the progress report on Day 1 of admission.

Choice B rationale:

Osteomyelitis is less likely to develop within the first 24 hours following a motor vehicle crash. It is an infection of the bone and typically takes more time to manifest. The early concerns in an open fracture involve the risk of infection, but osteomyelitis is not an immediate threat in this scenario.

Choice C rationale:

Compartment syndrome is a potential concern in orthopedic injuries, but it primarily arises due to increased pressure within a muscle compartment, causing reduced blood flow. While it is a valid concern, it is not typically associated with fat embolism syndrome, which is more specific to the release of fat globules into the bloodstream.

Choice D rationale:

Deep vein thrombosis (DVT) is a concern in immobile patients or those with significant trauma, but it is not the most immediate concern in this case. DVT usually develops over time and is more associated with prolonged immobilization rather than the early stages of admission.

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Correct Answer is C

Explanation

Answer isc. Keep the head of the bed raised while the tube feeding is infusing.

The client has a gastrostomy tube (GT), which is a tube inserted through the abdomen into the stomach for feeding purposes1.The PN should instruct the UAP to keep the head of the bed raised at least 30 degrees while the tube feeding is infusing, to prevent aspiration of the feed into the lungs2.Aspiration can cause pneumonia, which is a serious complication that can be fatal3.

a. Raising the entire bed while bathing the client to reduce back strain is not the most important instruction, because it does not address the risk of aspiration. The PN should also consider the client’s comfort and safety when adjusting the bed height. b. Reporting any drainage observed around the GT insertion site is not the most important instruction, because it is not directly related to the tube feeding. Drainage may indicate infection or leakage of the feed, which should be reported and managed accordingly. d. Using plenty of pillows to position the client on the side after bathing is not the most important instruction, because it is not specific to the tube feeding. Positioning the client on the side may help prevent pressure ulcers and improve circulation, but it does not prevent aspiration.

A. Tape the tube to the child's cheek. B. Apply water-soluble lubricant to the site. C. Attach an extension tube to the site's opening prior to use. D. Apply a skin barrier protectant to the site.

Correct Answer is D

Explanation

Choice A rationale:

Tape the tube to the child's cheek. Taping the tube to the child's cheek is not the recommended method for securing a gastrostomy enteral tube. It can cause discomfort and skin irritation for the child. Proper securing methods involve using specialized tube holders or dressings designed for this purpose.

Choice B rationale:

Apply water-soluble lubricant to the site. Rationale: Applying a water-soluble lubricant to the site is not a standard practice for gastrostomy tube care. It is essential to keep the site clean and dry to prevent infection. Lubricants are not typically used in this context.

Choice C rationale:

Attaching an extension tube is related to administering feedings or medications rather than the maintenance and care of the gastrostomy site. Site care focuses on protecting the skin and ensuring cleanliness around the tube insertion area.

Choice D rationale:

Apply a skin barrier protectant to the site. Using a skin barrier protectant helps shield the peristomal skin from irritation and breakdown caused by gastric contents and formula leakage.

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A nurse is assisting with the care of a client on an orthopedic unit. Exhibits Select words from the choices below to fill in each blank in the following sentence. The client is at risk for developing dropdown.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is providing instructions to the unlicensed assistive personnel (UAP) preparing to give a total bed bath to an immobile client who has a continuous feeding via gastrostomy tube (GT). Which instruction is most important for the PN to emphasize?

Correct Answer is C

Explanation

A nurse is providing site care for a child who has a gastrostomy enteral tube. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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A nurse is assisting with the care of a client on an orthopedic unit.

Exhibits

Select words from the choices below to fill in each blank in the following sentence.

The client is at risk for developing
dropdown
.