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 B
Explanation
The correct answer is choice B, a client who had abdominal surgery 2 days ago and the incision line is separating. This client requires immediate attention as a separating incision can indicate wound dehiscence or evisceration, which are surgical emergencies. Choice A is incorrect because although C. difficile is a serious infection, liquid stools are a common symptom and do not require immediate attention. Choice C is incorrect because intermittent coughing up clear sputum is a normal finding for a client with a tracheostomy, and does not indicate a change in the client's condition. Choice D is incorrect because the client fell 12 hours ago and reports pain as 4 on a scale of 0 to 10, which indicates a low level of pain.
Choice A: A client who has Clostridium difficile and has liquid stools is incorrect because although C. difficile is a serious infection, liquid stools are a common symptom and do not require immediate attention.
Choice C: A client who has a chronic tracheostomy and is intermittently coughing up clear sputum is incorrect because intermittent coughing up clear sputum is a normal finding for a client with a tracheostomy, and does not indicate a change in the client's condition.
Choice D: A client who fell 12 hours ago and reports pain as 4 on a scale of 0 to 10 is incorrect because the level of pain is low and does not require immediate attention.
Correct Answer is C
Explanation
Yankauer catheter. A Yankauer catheter is a suction device used for oral suctioning. It is important for this client to have access to a Yankauer catheter for safe and effective suctioning of secretions from the mouth.
Option A is incorrect because an Oropharyngeal airway is used to maintain or open the airway.
Option B is incorrect because the water-soluble lubricant is used for lubricating the suction catheter during suctioning.
Option D is incorrect because sterile gloves are not routinely needed for suctioning.
Reasons why the other options are not answered: Option A: An oropharyngeal airway is not used for suctioning but is used to maintain an open airway in an unconscious patient. Option B: Water-soluble lubricant is used for lubricating the suction catheter during suctioning. Option D: Sterile gloves are not routinely needed for suctioning.
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