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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
75 mL of greenish-yellow drainage should not be reported. This could be stomach contents or bile, which can be expected after surgery and might not be alarming.
Choice B reason:
150 mL of serosanguineous drainage should not be reported. Serosanguineous drainage is a mix of clear and slightly bloody fluid, which can be expected after surgery and may not be alarming.
Choice C reason:
100 mL of red drainage should be reported. After abdominal surgery, the drainage from an NG (nasogastric) tube is monitored to assess the client's condition and the status of their gastrointestinal system. Red drainage could indicate bleeding, which is a significant concern after surgery. The nurse should report this finding to the provider for further evaluation and intervention.
Choice D reason:
200 mL of brown drainage should not be reported. Brown drainage could also be indicative of old blood or digestive fluids, which might be expected after surgery and may not be alarming.
Correct Answer is C
Explanation
Choice A Reason:
Changing the catheter dressing daily - While it's important to maintain the dressing and keep it clean and dry, changing the dressing daily might not be necessary. The dressing should be changed according to facility policy and based on assessment findings.
Choice B Reason:
Cleaning the insertion site using 20 mL of hydrogen peroxide - Hydrogen peroxide is not recommended for cleaning PICC line insertion sites, as it can cause tissue irritation. The insertion site should be cleaned with an appropriate antiseptic solution per facility guidelines.
Choice C Reason:
Use a 10-mL syringe to flush the line. When completing discharge teaching for a client with a peripherally inserted central catheter (PICC) line, the nurse should include instructions regarding the proper care of the line. Using a 10-mL syringe to flush the line is the appropriate practice to prevent excessive pressure within the catheter and minimize the risk of catheter damage or rupture.
Choice D Reason:
Not elevating the arm above the level of the heart - Elevation of the arm above the heart level is generally not contraindicated for a PICC line. However, it's important to avoid activities that could lead to kinking or pulling on the line. The nurse should provide specific instructions regarding arm movement and care to the client.
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