The nurse is caring for a client who sustained a compound fracture of the right tibia/fibula postoperative ORIF (open reduction internal fixation). A complete assessment of the affected extremity would include:

Capillary refill, color of extremity.

Pedal pulses.

ACE wrap, Velcro boot, and hanging weights.

Pin sites.

Temperature, sensation, and movement of toes.

Answer and Explanation

Correct Answer : A,B,D,E

Choice a reason:
Assessing capillary refill and the color of the extremity is essential for determining the vascular status of the limb. A normal capillary refill time is less than 2 seconds and indicates good blood flow. The color should be consistent with the rest of the body, without pallor or cyanosis, which could indicate compromised circulation.

Choice b reason:
Checking pedal pulses is another critical aspect of assessing vascular integrity. The presence of strong and equal pulses in both feet suggests that the blood supply to the lower extremities is not compromised.

Choice c reason:
While the ACE wrap and Velcro boot are part of the postoperative management to provide support and protection to the affected limb, and hanging weights might be used for traction, these are not part of the physiological assessment of the extremity.

Choice d reason:
Monitoring pin sites for signs of infection, such as redness, swelling, or discharge, is crucial in a client with ORIF. Infection can lead to complications that may affect the healing process and the integrity of the fixation.

Choice e reason:
Evaluating the temperature, sensation, and movement of toes helps in assessing for potential nerve damage or compartment syndrome. Any changes in these parameters should be reported immediately as they may signify serious complications.

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Correct Answer is D

Explanation

Choice A Reason:

A blood pressure of 98/60, while on the lower side, is not necessarily alarming post-surgery unless the patient shows symptoms of hypotension or if there is a significant drop from the patient's baseline blood pressure. It is important to monitor trends in blood pressure readings rather than a single isolated measurement.

Choice B Reason:

A urine output of 40 mL/hour can be considered within normal limits post-surgery, as the expected urine output is at least 0.5 mL/kg/hr. However, it should be monitored closely to ensure that it does not decrease further, which could indicate renal complications.

Choice C Reason:

Pain rated as 5 on a 0-10 scale indicates moderate pain, which is expected post-surgery. Pain management should be continued as prescribed, and the patient should be reassessed regularly to ensure that the pain does not escalate.

Choice D Reason:

The absence of a popliteal pulse is a critical finding that must be reported immediately. The popliteal artery provides blood flow to the lower leg, and its absence could indicate graft occlusion or other serious circulatory issues, which could lead to limb-threatening complications if not addressed promptly.

A. Oral temperature of 100.6°F. B. Pulse oximetry of 98% on room air. C. Increased neutrophil count. D. Adequate urine output.

Correct Answer is B

Explanation

Choice A Reason

An oral temperature of 100.6°F may indicate that the client still has a fever, which could suggest ongoing infection. However, temperature alone is not the most reliable indicator of the effectiveness of antibiotic therapy, as it can be influenced by various factors.

Choice B Reason

Pulse oximetry measures the oxygen saturation of the blood, which is a direct indicator of respiratory function. For a client with pneumonia, an improvement in oxygen saturation to 98% on room air is a strong sign that the lungs are effectively exchanging gases and that the pneumonia is resolving. This would be a clear indication that the amoxicillin is effective.

Choice C Reason

An increased neutrophil count is a sign of acute infection, but it does not directly measure the effectiveness of the antibiotic therapy. Neutrophil counts can remain elevated even as the infection is resolving, so they are not the best sole indicator of therapeutic effectiveness.

Choice D Reason

Adequate urine output is important for overall health and indicates good kidney function, but it is not a direct measure of the effectiveness of antibiotic therapy for pneumonia. Urine output does not reflect the respiratory status or the resolution of lung infection.

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