The day after a 60-year-old patient has an open reduction and internal fixation (ORIF) for an open, displaced tibial fracture, the priority nursing diagnosis is
a. activity intolerance related to deconditioning.
b. risk for constipation related to prolonged bed rest.
c. risk for impaired skin integrity related to immobility.
d. risk for infection related to disruption of skin integrity.
ANS: D
A patient having an ORIF is at risk for problems such as wound infection and osteomyelitis. After an ORIF, patients typically are mobilized starting the first postoperative day, so problems caused by immobility are not as likely.
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The assessment that helps establish a diagnosis based on the identification of elements that may be an immediate threat to the client is a
1. nursing assessment. 2. risk factor assessment. 3. physical assessment. 4. rest factor assessment.
An infant born with congenital glaucoma is scheduled for surgery. Which preoperative order should the nurse question for this patient?
A) A preoperative antibiotic B) Nothing by mouth prior to surgery C) A preoperative injection of atropine D) Arm restraints to be applied after surgery
An 18-month-old child has been diagnosed with pediculosis capitis (head lice). Which prescription should the nurse question if ordered for the child?
a. Malathion (Ovide) b. Permethrin 1% (Nix) c. Benzyl alcohol 5% lotion d. Pyrethrin with piperonyl butoxide (RID)
For what problem is the client who cannot breathe through the nose because of a congenital bone obstruction at greater risk?
A. Dry respiratory tract membranes B. Frequent episodes of tonsillitis C. Development of nasal polyps D. Difficulty swallowing