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.
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 breakage1. Traction is usually applied to skeletal pins that are inserted into the bone without an external frame2.
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 policy3. 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C: Blood pressure change from 118/78 mm Hg to 86/50 mm Hg.
Choice C rationale: A significant drop in blood pressure can indicate various serious conditions, such as shock, hemorrhage, or a severe infection. The nurse should assess the client further and intervene as necessary to prevent complications.
Choice A rationale: The change in temperature may indicate the onset of a fever and requires further assessment, but it is not as immediately concerning as the sudden drop in blood pressure.
Choice B rationale: The change in respiratory rate could be a result of factors like pain, anxiety, or exercise. While it warrants further assessment, it is not as critical as the blood pressure change.
Choice D rationale: The heart rate change may be a response to medications, rest, or other factors. It should be monitored and assessed, but the priority finding is the blood pressure change, which may indicate a more severe underlying issue.
Correct Answer is C
Explanation
The correct answer is choice C. Asthma.
Choice A rationale:
Glaucoma is not a contraindication for propranolol. Beta-blockers like propranolol can actually be used to manage glaucoma by reducing intraocular pressure.
Choice B rationale:
Irritable bowel syndrome (IBS) is not a contraindication for propranolol. There is no direct interaction between propranolol and IBS that would prevent its use.
Choice C rationale:
Asthma is a contraindication for propranolol. Propranolol is a non-selective beta-blocker, which means it can block beta-2 receptors in the lungs, leading to bronchoconstriction and potentially severe asthma exacerbations.
Choice D rationale:
Migraine headaches are not a contraindication for propranolol. In fact, propranolol is often prescribed as a preventive treatment for migraines.
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