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 B
Explanation
Choice A reason:
"You are upset. We can talk about this later." This response acknowledges the client's feelings, but it doesn't actively engage in addressing the client's concerns. It might also give the impression that the nurse is avoiding the conversation.
Choice B reason:
"Why do you think your life is over?" This response shows empathy and encourages the client to share their thoughts and feelings. It provides an opening for a meaningful conversation and allows the nurse to better understand the client's perspective. This approach demonstrates active listening and a willingness to support the client emotionally.
Choice C reason:
"Would you like to meet with another client who is an amputee?" While connecting the client with another amputee might offer valuable perspective and support, it's important to address the client's immediate concerns and emotions first. This response doesn't directly address the client's statement about feeling that their life is over.
Choice D reason:
"Most people can adjust following this surgery."
While this response provides a general statement of reassurance, it may not fully acknowledge the client's emotions and concerns. It's important to validate the client's feelings and provide an opportunity for them to express themselves before offering reassurance.
Correct Answer is B
Explanation
Choice A Reason:
"I can give you a list of other people who had the same procedure." - This response might not address the client's concerns and could potentially violate privacy and confidentiality.
Choice B Reason:
"I can give you additional information about the procedure." Response B is an appropriate and supportive response. The client is expressing uncertainty about the mastectomy, so offering more information about the procedure can help the client make an informed decision. Providing accurate and detailed information allows the client to better understand their options and the potential benefits and risks of the procedure.
Choice C Reason:
"You will be cancer-free if you have the procedure." - Making a guarantee of being cancer-free after the procedure might be misleading and overly optimistic. While a mastectomy can treat cancer in some cases, it's important to provide realistic information.
Choice D Reason:
"You should get a second opinion regarding the procedure." - While seeking a second opinion can be valuable, this response might not directly address the client's immediate concerns about the procedure. Providing information first and then discussing the option of a second opinion might be a more balanced approach.
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