The student nurses ask the RN if a Foley catheter would be an appropriate intervention to protect intact skin for a patient who is not ambulatory, incontinent, and confused.
The nurse knows that it would be appropriate to ask the physician for an order to place a Foley catheter for this patient.

Choice A rationale

Removing the external fixator for a shower could compromise stabilization of the fracture. External fixators are designed to be left in place to maintain proper alignment and provide structural support for healing bones. Removing the device could introduce unnecessary risks, including increased mobility and potential damage to the fracture site.

Choice B rationale

Prolonged bed rest is not indicated for patients with external fixation devices unless medically necessary. Prolonged immobility can lead to complications such as deep vein thrombosis, muscle atrophy, or joint stiffness. Mobilization should be encouraged as tolerated to support recovery.

Choice C rationale

Proper cleaning of pin insertion sites prevents infection, a major risk with external fixation devices. Using sterile technique to clean the sites daily reduces bacterial colonization. Monitoring for signs of infection such as redness or drainage is critical to avoid osteomyelitis or systemic spread.

Choice D rationale

Prophylactic antibiotics are typically administered perioperatively but are not continued until device removal unless there are specific complications. Prolonged antibiotic use can lead to antimicrobial resistance and should only be used as clinically indicated to prevent or treat infection.

Choice A rationale

Checking blood pressure does not directly address the faint pulses and cool foot. While hypotension could contribute to peripheral perfusion issues, the signs described more likely indicate compartment syndrome, which requires urgent action.

Choice B rationale

Repositioning the leg might provide some comfort but does not alleviate the potential compartment syndrome. Elevation could worsen ischemia by reducing arterial blood flow.

Choice C rationale

Compartment syndrome is a medical emergency caused by increased pressure within a muscle compartment. This pressure compromises circulation and tissue viability. The nurse must notify the health care provider immediately to prevent permanent damage.

Choice D rationale

Assessing the incision for redness delays addressing the critical signs of potential compartment syndrome. Redness indicates infection, but faint pulses and a cool extremity necessitate more urgent evaluation.