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?
Maintain the affected extremity in a dependent position.
Palpate the dorsalis pedis pulse.
Wrap sterile gauze on the sharp point of the pins.
Adjust the clamps on the fixator frame.
The Correct Answer is B
Palpating the dorsalis pedis pulse is an essential action to monitor for adequate circulation and perfusion in an extremity with an external fixator, which is a device that stabilizes and aligns fractured bones with metal pins and rods outside of the skin. The other options are incorrect because they could cause complications such as edema, infection, or malalignment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Abdominal distension and firmness indicate increased intra-abdominal pressure, which can compromise blood flow to the bowel and cause ischemia, necrosis, or perforation.
The nurse should report this finding to the provider and assess for signs of shock or peritonitis.
Correct Answer is B
Explanation
Choice a.This response may come across as challenging or confrontational. While the nurse is asking for more information, the phrasing could inadvertently put the client on the defensive. It doesn't validate the client's feelings and may not encourage a productive dialogue.
- Choice b. “Suggesting peer support or mentorship from someone who has gone through a similar experience could be beneficial in some situations, as it may help the client feel less isolated.
- Choice c. “Most people can adjust following this surgery.” may be true, but it does not acknowledge the client’s individual experience and feelings. It may also sound dismissive or minimizing of the client’s challenges.
- Choice d. “You are upset. We can talk about this later.” may be intended to give the client some space, but it does not convey empathy or support. It may also make the client feel rejected or ignored.
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