A nurse is caring for a client who is 6 hr. postoperative following application of an external fixator for a tibial fracture. Which of the following actions should the nurse take?
Palpate the dorsalis pedis pulse.
Adjust the clamps on the fixator frame.
Wrap sterile gauze on the sharp point of the pins.
Maintain the affected extremity in a dependent position
The Correct Answer is A
Choice A reason:
Palpating the dorsalis pedis pulse is the appropriate option. Checking the dorsalis pedis pulse is crucial to assess the perfusion and circulation to the affected extremity. This is an important nursing action to monitor the patient's vascular status and ensure that there is adequate blood flow to the extremity distal to the fixator. A decrease or absence of the dorsalis pedis pulse could indicate potential circulation issues and require immediate attention.
Choice B reason:
Adjusting the clamps on the fixator frame is incorrect. The nurse should not adjust the clamps without specific orders from the healthcare provider. The external fixator is typically secured according to the surgeon's specifications, and any adjustments should be made under the guidance of the surgical team.
Choice C reason:
Wrapping sterile gauze on the sharp point of the pins is incorrect. The sharp pins used in an external fixator are an integral part of the device and are placed to stabilize the fracture. They should not be covered with sterile gauze, as this could interfere with their function and increase the risk of infection.
Choice D reason:
Maintaining the affected extremity in a dependent position is incorrect. Keeping the affected extremity in a dependent position (lower than the heart) can increase swelling and impair circulation. After surgery and fixation, it's often recommended to elevate the extremity to reduce swelling and promote proper circulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice Areason:
Placing pillows under the client's knees might be useful for comfort, but it doesn't directly address the risk of DVT.
Choice Breason:
Discouraging leg exercises while in bed is not recommended because it can lead to decreased circulation and an increased risk of blood clot formation.
Choice C reason:
Applying compression stockings to the lower extremities is recommendable. After an open cholecystectomy surgery, the client is at risk for developing deep vein thrombosis (DVT) due to reduced mobility and surgical trauma. Applying compression stockings to the lower extremities can help improve blood circulation and reduce the risk of blood clot formation.
Choice D reason:
Avoiding the use of anticoagulants is not recommendable, if prescribed by the healthcare provider, could be detrimental in preventing postoperative complications like DVT. Anticoagulants are often used to prevent clot formation in high-risk surgical patients.
Correct Answer is B
Explanation
Choice A reason:
"will keep my left arm flexed at the elbow as much as possible": This statement is incorrect because after a mastectomy, it's important to promote full range of motion in the affected arm to prevent complications like contractures and lymphedema.
Choice B reason:
“will have to wait 2 months before additional saline can be added to my breast expander" This is the correct statement. Following a modified radical mastectomy with a breast expander, additional saline is often added gradually to the expander to stretch the skin and muscle for reconstruction. The waiting period between saline additions allows for healing and proper tissue expansion. This statement indicates that the client understands the postoperative care and timeline.
Choice C reason:
"should expect less than 25 ml of secretions per day in the drainage devices": This statement is not accurate because the drainage amount can vary, and 25 ml per day might not be an accurate estimate.
Choice D reason:
"will perform strength-building arm exercises using a 15-pound weight": This statement is not appropriate, especially shortly after surgery. Gradual and gentle strength-building exercises are recommended, and using a 15-pound weight could be too strenuous and potentially harmful.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today