A nurse is caring for a client who is 6 hours postoperative following the application of an external fixator for a tibial fracture.
Which of the following actions should the nurse take?
Wrap sterile gauze on the sharp point of the pins.
Adjust the clamps on the fixator frame.
Maintain the affected extremity in a dependent position.
Palpate the dorsalis pedis pulse.
The Correct Answer is D
The nurse should palpate the dorsalis pedis pulse.
This is to assess for peripheral neurovascular dysfunction, which is a potential complication of a tibial fracture.
Choice A, wrapping sterile gauze on the sharp point of the pins, is not an answer because it is not mentioned in the search results as an intervention for a client with an external fixator for a tibial fracture.
Choice B, adjusting the clamps on the fixator frame, is not an answer because it is not mentioned in the search results as an intervention for a client with an external fixator for a tibial fracture.
Choice C, maintaining the affected extremity in a dependent position, is not an answer because it is not mentioned in the search results as an intervention for a client with an external fixator for a tibial fracture.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
First-degree heart block is a type of atrioventricular (AV) block that involves the consistent prolongation of the PR interval (defined as >0.20 seconds) due to delayed conduction via the atrioventricular node.
This is seen on an ECG as a PR interval greater than 200 ms in length.
Choice B: Nondiscernible P waves are not an answer because it is not mentioned as a characteristic of first-degree heart block in my sources.
Choice C: More P waves than QRS complexes is not an answer because it is not mentioned as a characteristic of first-degree heart block in my sources.
Choice D: No correlation between P and QRS waves is not an answer because it is not mentioned as a characteristic of first-degree heart block in my sources.
Correct Answer is B
Explanation
The correct answer is choice B: Insert an NG tube.
Choice A rationale: Inserting an indwelling urinary catheter may be necessary for monitoring urine output in some cases, but in this situation, the priority is to insert an NG tube. This will help prevent aspiration during surgery due to the client's high blood alcohol level, which increases the risk of vomiting.
Choice B rationale: Inserting an NG tube is the priority action for the nurse because a high blood alcohol level increases the risk of vomiting and aspiration during surgery. An NG tube can help reduce this risk by keeping the stomach empty and minimizing the chance of aspiration.
Choice C rationale: Obtaining consent for surgery is important, but in emergency situations, consent may be implied, or a designated surrogate decision-maker may provide consent. It is not the priority action for the nurse in this scenario.
Choice D rationale: Applying antiembolic stockings is a preventive measure for deep vein thrombosis, but it is not the priority action in this case. Ensuring the client's safety during surgery, specifically by preventing aspiration, takes precedence due to the client's high blood alcohol level.
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