The nurse is caring for a client with external fixation of the tibia. Which of the following would the nurse include in the plan of care?
Removing and applying the fixator for showers.
Documenting pin site assessment and care.
Encouraging the patient to lie prone several times per day.
Turning the patient every 3 hours.
The Correct Answer is B
A. Removing and applying the fixator for showers is not appropriate. The external fixator should not be removed by the nurse without proper medical guidance. Showers should be managed in a way that prevents the fixator from becoming wet or contaminated.
B. Documenting pin site assessment and care is essential for clients with external fixation. The nurse should regularly assess pin sites for signs of infection (e.g., redness, swelling, drainage) and ensure proper care is provided to prevent complications.
C. Encouraging the patient to lie prone several times per day may not be necessary or appropriate unless specifically ordered by the provider. The patient’s positioning should be based on comfort and the provider’s instructions to avoid strain on the injured limb.
D. Turning the patient every 3 hours is a general nursing practice for preventing pressure ulcers, but it is not specific to the care of a client with external fixation. The focus should be on protecting the fixator and ensuring the limb is properly supported.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Flushed skin is typically associated with fever or infection, not with hyponatremia (low sodium levels).
B. Confusion is a common symptom of hyponatremia, especially when sodium levels drop significantly. The low sodium level affects brain function, leading to confusion, altered mental status, and even seizures in severe cases.
C. Extreme thirst is more commonly seen in hypernatremia (high sodium levels) as the body attempts to correct the imbalance by stimulating thirst.
D. Fever is not a direct consequence of hyponatremia but could be associated with an underlying infection or other conditions.
Correct Answer is ["A","C","D"]
Explanation
A. Excessive thirst (polydipsia) is a common symptom of hyperglycemia due to dehydration caused by increased urination.
B. Anxiety and tremors are more commonly associated with hypoglycemia (low blood sugar), not hyperglycemia.
C. Excessive urination (polyuria) is a hallmark of hyperglycemia as the body attempts to excrete excess glucose through urine.
D. "Acetone" or "fruity" breath odor is a characteristic sign of diabetic ketoacidosis (DKA), which can occur in severe hyperglycemia.
E. Slow, shallow respirations are not typically associated with hyperglycemia but may occur in cases of respiratory acidosis or DKA, where Kussmaul's breathing (deep, rapid breathing) is more common.
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