A nurse is caring for a client in hospice care who is dying. The client's partner expresses concern that the client is sleeping more than in the previous week. Which of the following is an appropriate response by the nurse?

The correct answer is Choice C.

Choice A rationale: Applying traction weight to the external fixator is not recommended, as it can cause excessive stress on the pins and wires, leading to complications such as infection, loosening, or breakage1.Traction is usually applied to skeletal pins that are inserted into the bone without an external frame2.

Choice B rationale: Monitoring the neurovascular status of the affected limb is important, but every 8 hours is not frequent enough.The nurse should perform neurovascular checks every 2 to 4 hours for the first 24 hours, then every 4 to 8 hours, according to the facility policy3. This is to assess for signs of nerve damage, compartment syndrome, or impaired circulation, which can result from the injury or the device.

Choice C rationale: Administering pain medication 30 min prior to pin care is a correct intervention, as it can help reduce the discomfort and anxiety associated with the procedure. Pin care involves cleaning the pin sites with an antiseptic solution and applying sterile dressings to prevent infection and promote healing. The frequency and technique of pin care may vary depending on the type of device, the condition of the wound, and the facility protocol.

Choice D rationale: Adjusting the clamps on the device’s frame daily is not a nursing intervention, as it can alter the alignment and stability of the fracture. The clamps should be tightened only by the orthopedic surgeon or a trained technician, and only when necessary. The nurse should inspect the device for any loose or broken parts and report any problems to the surgeon.

So, the correct answer is Choice C, after analysing all choices.

The correct answer is choice D. Allow frequent rest periods.

Choice A rationale:

Encouraging fluids is not appropriate for a client with heart failure. Clients with heart failure often experience fluid overload due to the heart’s inability to pump effectively, leading to fluid retention.Encouraging additional fluid intake can exacerbate this condition, worsening symptoms such as edema and shortness of breath.

Choice B rationale:

Measuring vital signs every 8 hours may not be frequent enough for a client with heart failure, especially if they are experiencing acute symptoms.More frequent monitoring is often necessary to detect changes in the client’s condition promptly and to manage symptoms effectively.

Choice C rationale:

Obtaining weight weekly is not sufficient for a client with heart failure. Daily weight monitoring is crucial as it helps in detecting fluid retention early.Sudden weight gain can indicate worsening heart failure and the need for adjustments in treatment.

Choice D rationale:

Allowing frequent rest periods is essential for clients with heart failure. These clients often experience fatigue and decreased exercise tolerance due to reduced cardiac output.Frequent rest periods help in managing fatigue and preventing overexertion, which can worsen heart failure symptoms.