A nurse is contributing to the plan of care for a client who has an external fixation device in place to treat an open fracture of the tibia and fibula. Which of the following interventions should the nurse include?

Apply 4.5 kg (10 lb) traction weight to the distal end of the fixator.

Monitor the neurovascular status of the client's affected limb every 8 hr.

Administer pain medication 30 min prior to pin care.

Adjust the clamps on the device's frame daily.

Answer and Explanation

The Correct Answer is C

The correct answer is Choice C.

Choice A rationale: Applying traction weight to the external fixator is not recommended, as it can cause excessive stress on the pins and wires, leading to complications such as infection, loosening, or breakage 1. Traction is usually applied to skeletal pins that are inserted into the bone without an external frame 2.

Choice B rationale: Monitoring the neurovascular status of the affected limb is important, but every 8 hours is not frequent enough. The nurse should perform neurovascular checks every 2 to 4 hours for the first 24 hours, then every 4 to 8 hours, according to the facility policy 3. This is to assess for signs of nerve damage, compartment syndrome, or impaired circulation, which can result from the injury or the device.

Choice C rationale: Administering pain medication 30 min prior to pin care is a correct intervention, as it can help reduce the discomfort and anxiety associated with the procedure. Pin care involves cleaning the pin sites with an antiseptic solution and applying sterile dressings to prevent infection and promote healing. The frequency and technique of pin care may vary depending on the type of device, the condition of the wound, and the facility protocol.

Choice D rationale: Adjusting the clamps on the device’s frame daily is not a nursing intervention, as it can alter the alignment and stability of the fracture. The clamps should be tightened only by the orthopedic surgeon or a trained technician, and only when necessary. The nurse should inspect the device for any loose or broken parts and report any problems to the surgeon.

So, the correct answer is Choice C, after analysing all choices.

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Correct Answer is A

Explanation

The correct answer is choice A, Perform suctioning. Restlessness and crackles in the lungs may indicate respiratory distress or airway obstruction, which may be due to mucus or secretions blocking the tracheostomy tube. Performing suctioning helps clear the airway of secretions, which will improve the client's breathing. Choice B is incorrect because instilling saline into the tubing is not a common intervention for managing restlessness and crackles. Choice C is incorrect because checking the cuff pressure is not related to managing restlessness and crackles. Choice D is incorrect because increasing humidification is not a common intervention for managing restlessness and crackles.

Other choices:

Instill saline into the tubing: Instilling saline into the tubing is not a common intervention for managing restlessness and crackles.

Check the cuff pressure: Checking the cuff pressure is not related to managing restlessness and crackles.

Increase the humidification: Increasing humidification is not a common intervention for managing restlessness and crackles.

A. Close the door to the client's room. B. Obtain a fire extinguisher. C. Pull the fire alarm panel. D. Remove the client from the room.

Correct Answer is D

Explanation

The correct answer is Choice D.

Choice A rationale: Closing the door to the client’s room would help to contain the fire and prevent it from spreading to other areas. However, this should not be the nurse’s first action. The nurse’s primary responsibility is to ensure the safety of the client. Therefore, removing the client from the room should be the first action taken.

Choice B rationale: Obtaining a fire extinguisher is an important step in responding to a fire. However, it should not be the first action taken by the nurse. The nurse’s primary responsibility is to ensure the safety of the client. Therefore, removing the client from the room should be the first action taken.

Choice C rationale: Pulling the fire alarm panel is an important step in alerting others in the facility about the fire. However, it should not be the first action taken by the nurse. The nurse’s primary responsibility is to ensure the safety of the client. Therefore, removing the client from the room should be the first action taken.

Choice D rationale: The nurse’s primary responsibility is to ensure the safety of the client. If there is a fire in the client’s room, the nurse should first remove the client from the room to ensure their safety. Once the client is safe, the nurse can then take further actions to respond to the fire, such as pulling the fire alarm panel, closing the door to the room, and obtaining a fire extinguisher.

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A nurse is contributing to the plan of care for a client who has an external fixation device in place to treat an open fracture of the tibia and fibula. Which of the following interventions should the nurse include?

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