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

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A reason:

Listening to the client's bowel sounds should not be implemented. It is important for assessing the gastrointestinal status, but the priority in this situation is to address the potential cardiac complications of hypokalaemia.

Choice B reason:

Initiating cardiac monitoring for the client should be implemented. A serum potassium level of 2.8 mEq/L is significantly low (normal range is typically around 3.5-5.0 mEq/L). Low potassium levels, known as hypokalaemia, can lead to serious cardiac arrhythmias and other complications. Therefore, the nurse should prioritize cardiac monitoring to assess for any potential changes or abnormalities in the client's heart rhythm due to the low potassium levels.

Choice C reason:

Checking the client's hand grasps should not be implemented. It is a test for muscle strength and can be indicative of hypokalaemia, but initiating cardiac monitoring is more critical at this point.

Choice D reason:

Administering an IV potassium drip may be necessary, but initiating cardiac monitoring takes precedence as the first action to ensure the client's heart rhythm is stable before addressing the potassium imbalance.

A. Blurred vision B. Polyuria C. Diarrhea D. Confusion

Correct Answer is D

Explanation

Choice A Reason:

Blurred vision is incorrectly. Blurred vision is not a common complication of immobility and is more likely related to other factors.

Choice B Reason:

Polyuria is incorrect. Increased urination (polyuria) is not directly related to immobility; it can be caused by various factors, such as fluid intake, medications, or underlying medical conditions.

Choice C Reason:

Diarrhea is incorrect. While immobility can contribute to constipation due to reduced activity and decreased bowel motility, it is not typically associated with diarrhea

Choice D Reason:

Confusion is correct. Confusion can be a potential complication of immobility in bedridden clients. Prolonged immobility can lead to reduced sensory stimulation, altered sleep patterns, and decreased cognitive engagement, which can contribute to confusion and cognitive decline.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

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