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 B

Explanation

Choice A rationale

Hypertension is not typically a sign of heart failure related to cor pulmonale. It is more associated with systemic issues rather than pulmonary complications.

Choice B rationale

Peripheral edema is a common sign of heart failure and cor pulmonale due to increased pressure in the venous system, leading to fluid accumulation in the tissues.

Choice C rationale

Increased respiratory rate may occur but is not specific to heart failure in cor pulmonale.

Choice D rationale

Cough with pink-tinged sputum is more indicative of pulmonary edema related to left-sided heart failure rather than cor pulmonale.

A. A condition in which there is a puncture or rupture of the lung. B. A condition characterized by the presence of air or gas in the pleural cavity. C. A condition characterized by multiple fractures of the ribs resulting in a segment of the chest wall becoming detached. D. A condition characterized by the collapse of the lung.

Correct Answer is C

Explanation

Choice A rationale

A puncture or rupture of the lung is typically associated with a pneumothorax, not flail chest. Pneumothorax occurs when air leaks into the space between the lung and the chest wall.

Choice B rationale

The presence of air or gas in the pleural cavity is known as pneumothorax. Flail chest, however, is characterized by multiple rib fractures.

Choice C rationale

Flail chest occurs when multiple adjacent ribs are fractured in multiple places, creating a free-floating segment of the chest wall. This condition is serious and often results from blunt chest trauma.

Choice D rationale

The collapse of the lung is known as atelectasis or pneumothorax, not flail chest. Flail chest specifically refers to the detachment of a segment of the rib cage.

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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

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Correct Answer is B

Explanation

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Correct Answer is C

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?