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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

The client should wash their perineal area twice a day with antimicrobial soap to prevent infection and irritation. This is especially important for clients who have an impaired immune system due to chemotherapy, as they are more susceptible to infections and complications.

A. "I will empty my bag when it is full." B. "I will take a laxative when I'm constipated." C. "I will expect my stools to be loose." D. "I will eat a high-fiber diet."

Correct Answer is C

Explanation

An ileostomy is a surgical opening in the abdomen that connects the end of the small intestine (ileum) to a pouch or bag on the outside of the body. The ileostomy bypasses the large intestine (colon) and rectum, which normally absorb water and form solid stools. Therefore, the client should expect their stools to be loose and watery. The client should empty their bag several times a day, not when it is full, to prevent leakage and skin irritation. The client should avoid laxatives, which can cause dehydration and electrolyte imbalance. The client should also avoid high-fiber foods, which can cause blockage or irritation of the ileostomy.

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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

A nurse is providing discharge teaching to a client who has an impaired immune system due to chemotherapy. Which of the following information should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is providing discharge teaching to a client who has an ileostomy. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse?

A nurse is assessing a client who is preoperative and reports an allergy to bananas. The nurse should recognize that the client is at risk for an allergic cross-reactivity to which of the following substances?

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A nurse is assessing a client who has acute kidney failure. Which of the following findings should the nurse report to the provider?

A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client who understands a prescribed surgical procedure, but cannot read or write. Which of the following actions should the nurse take?

A nurse is reviewing the following ABG results for a postoperative client: pH 7.27, PaCO2 49 mm Hg, PaO2 65 mm Hg, HCO 22 mEq/L. The nurse should interpret the findings as which of the following imbalances?

A nurse is providing dietary teaching to a client who has heart failure and a new prescription for a 2-g sodium diet. Which of the following client statements should the nurse identify as an understanding of the teaching?