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 irritation, 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 nurse should notify the provider immediately. 2. Stop the blood transfusion immediately. A client who has type AB-positive blood is considered a universal recipient and can receive any ABO blood type. A client who has Rh-positive blood can receive a transfusion from a Rh-negative donor. Prepare to administer antipyretics. Febrile reactions are most often caused by leukocyte incompatibilities. Unless a client has a history of febrile reactions to prior transfusions or shows signs of chills or fever, there is no reason to administer antipyretics. Monitor the client for any adverse reactions. MY ANSWER Although a client is considered a universal recipient because he can receive any ABO blood type, the nurse should continue to monitor the client for any adverse reactions, which is standard procedure for any blood transfusion.