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Dif applyingapplication ref 1034 key fracture

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DIF: Applying/Application REF: 1034KEY: Fracture| pulmonary embolism| respiratory distress/failure| older adultMSC: Integrated Process: Nursing Process: ImplementationNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care6.A trauma nurse cares for several clients with fractures. Which client should the nurse identify as athighestriskfordevelopingdeep veinthrombosis?a.An18-year-oldmaleathletewithafracturedclavicleb.A36-yearoldfemalewithtype2diabetesandfracturedribsc.A55-year-oldwomanprescribedaspirinforrheumatoidarthritisd.A74-year-old manwhosmokesand has afracturedpelvisANS: DDeep vein thrombosis (DVT) as a complication with bone fractures occurs more often when fractures aresustained in thelowerextremitiesandtheclienthasadditionalriskfactorsforthrombusformation. Otherriskfactors include obesity, smoking, oral contraceptives, previous thrombus events, advanced age, venousstasis, and heart disease. The other clients do not have risk factors for DVT.DIF: Applying/Application REF:1034 KEY: Fracture| healthscreeningMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care7.Anurse delegatescareofa clientin tractiontoanunlicensedassistivepersonnel (UAP).Whichstatementshouldthenurseincludewhendelegatinghygienecareforthisclient?
a. Remove the traction when re-positioning the client.
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b. Inspect the clients skin when performing a bed bath.c. Provide pin care by using alcohol wipes to clean the sites.d.Ensurethattheweightsremainfreelyhangingatalltimes.ANS: DTraction weights should be freely hanging at all times. They should not be lifted manually or allowed torest on the floor. The client should remain in traction during hygiene activities. The nurse should assess theclients skin and provide pin and wound care for a client who is in traction; this should not be delegated tothe UAP.DIF: Applying/Application REF: 1040KEY: Traction|fracture|delegation|unlicensedassistivepersonnel(UAP)MSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care8.Anursenotescrepitationwhenperformingrange-of-motionexercisesonaclientwithafracturedlefthumerus.Which actionshould the nursetakenext?a.Immobilizetheleftarm.b. Assess the clients distal pulse.c. Monitor for signs of infection.d. Administer prescribed steroids.ANS: AA grating sound heard when the affected part is moved is known as crepitation. This sound is created bybone fragments. Because bone fragments may be present, the nurse should immobilize the clients arm andtell the client not to move the arm. The grating sound does not indicate circulation impairment or infection.Steroids would not be indicated.

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Term
Fall
Professor
N/A
Tags
Nursing, Test, Management of Care, The Grave,

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