*NURSING > MED-SURG EXAM > Assessment RN VATI Adult Medical Surgical 2016 (All)
Assessment RN VATI Adult Medical Surgical 2016
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Assessment RN VATI Adult Medical Surgical 2016 1. Inspect the client's skin underneath the boot every 12 hr. The nurse should inspect the client’s skin underneath the boot every 8 hr for i... rritation, increased swelling, and skin breakdown. Remove the weights from the traction while repositioning the client in bed. MY ANSWER The nurse should not remove the weights from traction without a prescription from the provider. The purpose of the weight is to immobilize the hip prior to surgery and to decrease muscles spasms. Assess the client's circulation every 4 hr. The nurse should assess the client's circulation hourly for the first 24 hr to monitor for decreased perfusion and neurovascular changes. Request the client to perform dorsiflexion of the affected extremity every 1 hr. The nurse should request the client to perform dorsiflexion of the affected extremity every 1 hr to assess if the client is experiencing nerve damage. Weakness of dorsiflexion can indicate peroneal nerve damage. If this occurs, the ..................................continued [Show More]
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