The nurse is caring for a patient who has a pelvic fracture and an external fixation device.
How should the nurse perform assessment of pressure areas and provide skin care to the patient's back and sacrum?

Have the patient lift the back and buttocks using a trapeze.

Ask the patient to turn to the side independently.

Roll the patient over to the side by pushing on the patient's hip.

Defer back assessment until the patient is ambulatory.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Having the patient lift their back and buttocks using a trapeze allows for proper assessment of pressure areas and skin care. This technique reduces the risk of further injury or discomfort and provides better access for the nurse to assess the skin condition.

Choice B rationale

Asking the patient to turn to the side independently may not be feasible for a patient with a pelvic fracture. This method can cause pain and risk further injury, making it an unsuitable choice for assessing pressure areas.

Choice C rationale

Rolling the patient over to the side by pushing on the patient's hip is not recommended as it can exacerbate the injury and cause pain. This method is not appropriate for patients with pelvic fractures.

Choice D rationale

Deferring back assessment until the patient is ambulatory is not a safe practice. Pressure areas should be regularly assessed to prevent skin breakdown and complications, even if the patient is not yet ambulatory.

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Correct Answer is C

Explanation

Choice A rationale

Hypertension is not a typical finding associated with community-acquired pneumonia. The condition more commonly presents with respiratory symptoms such as cough, fever, and difficulty breathing.

Choice B rationale

Unequal pupils are not a common finding in community-acquired pneumonia and could indicate a neurological issue or head injury, which would require further investigation.

Choice C rationale

Confusion, particularly in older adults, can be a symptom of community-acquired pneumonia. It is often due to hypoxia or systemic inflammation and is a sign of a more severe infection.

Choice D rationale

Tympany upon chest percussion is not expected in pneumonia. Pneumonia typically presents with dullness on percussion due to the consolidation of lung tissue, not the hyperresonance that causes tympany.

A. Reduced bronchospasm. B. Decreased breathlessness. C. Increased carbon dioxide retention. D. Improved oxygen saturation levels.

Correct Answer is D

Explanation

Choice A rationale

Reduced bronchospasm is a beneficial outcome for COPD, but it is not the primary outcome related to gas exchange.

Choice B rationale

Decreased breathlessness is a positive outcome for COPD, but it is not directly related to gas exchange.

Choice C rationale

Increased carbon dioxide retention is a negative outcome and indicates worsening of gas exchange.

Choice D rationale

Improved oxygen saturation levels are a direct and measurable outcome of effective gas exchange and indicate better oxygenation in COPD patients.

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The nurse is caring for a patient who has a pelvic fracture and an external fixation device.How should the nurse perform assessment of pressure areas and provide skin care to the patient's back and sacrum?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is assessing an older adult client who has community-acquired pneumonia.Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

Which outcome is appropriate for the client problem of "ineffective gas exchange" for the client diagnosed with chronic obstructive pulmonary disease (COPD)?

Correct Answer is D

Explanation

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The nurse is caring for a patient who has a pelvic fracture and an external fixation device.
How should the nurse perform assessment of pressure areas and provide skin care to the patient's back and sacrum?