Oversensing is when the sensing threshold is too high causing the pacer to sense any electrical activity as a P or QRS including electromagnetic energy from outside the patient. QRS: An electric spike is seen before a wide, ventricular QRS. morphology should be identical, based on its origin Rifampin P waves: Depends on underlying rhythm Rhythm: Regular with late beat Which of the following information should the nurse include in the teaching? PRI: If P wave is present before QRS, < 0.12 sec. P waves: None time between the onset of ventricular depolarization and the end of repolarization Rhythm: Regular A postoperative laparoscopic appendectomy patient is receiving morphine PCA for pain findings with alert you to the potential of a narcotic overdose? Which of the following statements should the nurse make? Discarded, then begin the 24 hour collection. Rhythm: Depends on underlying rhythm Which of the following actions is the nurse's priority? Compare. Alternate application of heat and cold to the affected joints. P waves: One before every QRS Your patient fell and hit his head on the bed rail during a physical therapy session. A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and notes clots in the client's indwelling urinary catheter and a decrease in urinary output. The patient has a morphine PCA post operatively. Changes in the shape or height above or below the baseline is abnormal and indicative of pathology, most often a sign of myocardial injury as seen in an acute MI. blastocyst. What should be your next step? and you know dark tarry stool what would be the diagnosis? You're reviewing the discharge medication list of a patient diagnosed with gastric ulcer. QRS: 0.06-0.10(12) PRI: 0.12-0.20 sec A nurse is planning care for a client who has a sealed radiation implant for cervical cancer. And ABG was drawn and the results are pH? (Select all that apply.). Which of the following should be implemented? Perform a bladder scan P waves: As with PJCs A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr ago. BEGIN: beginning of Q They report sudden chest pain pulse ox at 86%. What is most likely to be ordered? QRS: > 0.12 sec. HCO3 - 23. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? One of the first signs of hemorrhage is an increase in the heart rate from the client's baseline, which occurs to compensate for blood loss. A nurse is providing follow-up care for a client who sustained a compound fracture 3 weeks ago. When there -Junction or AV node Correct Answer: Laryngeal strider Which of the following actions would be considered a violation of Hyppa? Air flows from a large tank at p = 650 kPa absolute, T = 550C^{\circ} \mathrm{C}C through a converging nozzle, with a throat area of 600 mm2^{2}2, and discharges to the atmosphere. PRI: None Which of the following actions should the nurse take? The download is temporarily disabled. Which of the following instructions should the nurse include? P waves: An electric spike is seen before a small, atrial P wave representing atrial capture. QRS: 0.06-0.10(12) if juctional rhythm is the escape mechanism. Due to the size of the kidney stone it is an appropriate treatment? Administer ranitidine, A nurse is assessing heart sounds of a client who reports substernal precordial pain. Pediatric RN. the following medication should you question? You're preparing your patient for discharge need to provide dietary education related to his Disequilibrium syndrome is caused by the rapid removal of electrolytes from the client's blood and can lead to dysrhythmias or seizures. Acts like a resistor to slow the impulse allowing time for the atria to completely contract before initiating ventricular contraction. Didn't nurse ask you about the typical signs and symptoms of myocardial infarction, Women could have pain in their arm, neck, back or jaw, While performing the narcotic count at the end of the shift, my coworker admits to something, coworker to sign for the ways that you did not witness. The nurse is taking care of a patient who is terminally ill and has a DNR on file. The amount available is oral solution 125 mg/5 mL. -arrest Drink 240 mL (8 oz) of water after administration. Explorerecent.com is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to Amazon.com. A nurse is planning care for a client who is having a modified radical mastectomy of the right breast. Prophecy Medical Surgical Telemetry Exam A V1. PRI: 0.12-0.20 sec Neck If a 60 dB sound increases to 70 dB, about how much louder is the sound: Because of its chemical similarity to calcium, ${ }_{38}^{90}$ Sr can collect in the bones and present a health risk. reads at 25 mm/sec 111 0 obj <>stream Back up pacemaker if SA fails, pacing at a rate of 40-60 times a minute. You're preparing your patient for discharge need to provide dietary education related to his diagnosis what should you instruct the patient to avoid? per minute O2 saturation of 82%. Rate: Depends on underlying rhythm. However, with a little practice and perseverance, anyone can . following resources would be most appropriate to utilize in order to obtain consent? 226 Math Experts 3 Years in business . PRI: If P is visible, 0.12-0.20 sec A nurse is caring for a client who has diabetic ketoacidosis (DKA). Type II Second-Degree AV Block The nurse should identify which of the following findings as an indication of a myocardial infarction (MI)? Keep the client occupied with a manual activity. A nurse is teaching a family about the care of a parent who has a new diagnosis of Alzheimer's disease. The symptoms are indicative of: You're reviewing the menu list of a patient on Warfran what food should they not eat? This can be due to lead dislodgement. (Click on the audio button to listen to the clip.). Which of the following issues should be reported up the chain of command, A coworker arriving to work under the influence of alcohol. Your patient began deteriorating rapidly after complaining of shortness of breath. A nurse is reviewing the laboratory results of a client who has AIDS and is taking amphotericin B for a fungal infection. a sudden cardiac arrest and family wants CPR initiated. 100% (2 ratings) Option C, Give CPR immediately . -first degree AV block (Click on the "Exhibit" button for additional information about the client. PRI: None when QRSs are not present Expert Help. Initiate IV therapy you usually have to score over 80% to pass. Patterns: Bi and trigemeny, couplets and triplets, Rate: Depends on underlying rhythm END: start of t wave Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Civilization and its Discontents (Sigmund Freud), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Give Me Liberty! PRI: Same as PVC A nurse is assessing a client who has diabetes insipidus. Rhythm: Regular Increased heart rate A nurse is caring for a client who has active bleeding from peptic ulcer disease. Prepare to suction the client's airway. Which of the following statements should the nurse make? How should you respond? Upper G. bleed Correct Answer: Honor the patient's wishes Correct Answer: Not normal sinus rhythm into a flutter Correct answer is ventricular fibrillation Your patient began deteriorating rapidly after complaining of shortness of breath. a result of impaired arterial circulation affecting follicular growth. You notify the physician and anticipate which diagnosis? Which of the following antidiabetic medication is contraindicated 48 hours after receiving contrast dye, You're a king for a patient who is postop after surgical removal of fibroids. earth, for how long (in terms of TTT ) would they be in the air on Mars? Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever) Interpersonal Communication (Kory Floyd) . The pacer begins pacing when the HR is 60 or below. premature junctional contraction A nurse is providing education to a client who has tuberculosis (TB) and their family. PRI: 0.12-0.20 sec Rhythm: Regular Which of the following orders would you question. PRI: Progressively longer until QRS drops. "This identifies if the pacemaker cells of my heart are working properly." Rhythm: Regular except for pause Usually set to pace if ventricular rate <60 BEGIN: J point -accelerated junctional rhythm . Lipase and amylase -bundle branch block Prophecy medical surgical-telemetry You are to obtain informed consent for a Spanish-speaking patient scheduled for surgery. NUR 4201. . Do you notice the spouse adjusting the oxygen on the There are three tabs that contain separate categories of data. This image depicts glossitis, which can indicate pernicious anemia. (Click on the audio button to listen to the clip.) 6: Measure the QT interval, variation of R-R less than 0.12 seconds = regular amplitude 0.5-2.5 mm, 0.10 seconds or less, damaged atria (enlarged makes p wave look like an "m") or an impulse origin outside of the SA node (ectopic), Start: beginning of P For which of the following adverse effects should the nurse instruct the client to notify the provider? A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation. -paroxysmal atrial tachycardia If the ventricles generates an impulse, the pacemaker will not fire. You are taking care of a patient who is admitted for left flank pain with a kidney stone of 1 cm. How is it affecting indigenous people? Aim. 1520 Rhythm: Regular After notifying the physician, what action should you take NEXT? The nurse should identify that which of the following values is an indication of an adverse effect of the medication? count R waves during 6 seconds and multiply by 10, A) P should precede QRS Prophecy medical surgical-telemetry You are to obtain informed consent for a Spanish-speaking patient scheduled for surgery. P waves: none Which of the following resources would be most appropriate to utilize in order to . Rhythm: Irregular "Spike and capture". Stress ulcers increase the risk for systemic infection and require pharmacological treatment. Correct Answer: The hospitals language interpreter You're reviewing the discharge medication list of a patient diagnosed with gastric ulcer. Bubbling in the water seal chamber has ceased. Low back pain and apprehension Medical-surgical practice exam. The client should increase fiber intake to promote regular bowel function. Prophecy health medical surgical RN A (Latest 2022/2023). Rhythm: Regular with late beats You're providing discharge instructions to a CHF patient. Surgery Medical-Surgical RN A Prophecy Relias 4.2 (9 reviews) Term 1 / 99 1.2 milligrams is equal to how many micrograms? Divides into the bundle branches. $$ Aspirate the fluid, advance the catheter farther, then re-inflate the balloon. Which of the following findings should indicate to the nurse that the client's condition is improving? P waves: Present Pulmonary embolism? reasons: electrolyte imbalances, left vent hypertrophy, medications. Hemodialys is something required following surgery What information is vital for you to know prior to administering an ordered dose of digoxin A. Exacerbation of abdominal tissue growth B. Bony articular surfaces in joint exposed C. Fragile, soft, dull joint cartilage develops An animal with many lines of symmetry a. has bilateral symmetry. Study Resources. Meclizine can also be used for the treatment of vertigo or other conditions including nausea, vomiting, and insomnia. When an arrhythmia arises from the AV or Junction, the impulse travels to both the atria (retrograde) and the ventricles (antegrade). Which of the following electrolyte value should be Addressed immediately by the nurse, Which of the following medication may cause urine discoloration, Calculate the 12 hour intake for a patient that has received the following during your shift: normal saline 750 ML, 24 ounces of sprite, Levaquin 50 ML, 650 ML urine in Foley catheter. Julie S Snyder, Linda Lilley, Shelly Collins, Medical Terminology: Learning Through Practice. Clinical Results - Medical Surgical-Telemetry A v1 Assessment. Essential Environment: The Science Behind the Stories Jay H. Withgott, Matthew Laposata. A nurse is admitting a client who has active tuberculosis. Pulmonary embolism Terms of Use Deposition has ordered for your patience to begin a 24 hour urine collection. Rhythm: Regular Which of the following actions should the nurse take? Ibuprofen can cause gastrointestinal bleeding in older adult clients. 2: Calculate the heart rate. Exam Objective: To measure the overall clinical knowledge of the. When caring for a patient experiencing a tonic clonic seizure, the most appropriate nursing Terminal fibers branches from the bundles, distributing the impulse throughout the ventricles. The will exhibit multiple manifestations, including bradycardia, severe headache, and flushing. Which of the following is true about the formation and migration of meanders? Which of the following findings should the nurse expect? A home health nurse is providing teaching to a client who has a stage 1 pressure injury on the greater trochanter of his left hip. The ventricles are paced and sensed. Which of the following actions should the nurse take first? Scan the bladder with a portable ultrasound. Prophecy Medical Surgical Exam Answers Orris. P waves: Present Rhythm: Regular except for pause. Which of the following information should the nurse provide? PRI: 0.12-0.20 sec ), AdminiSTER o2 Third-Degree AV Block, Rate: Depends on underlying rhythm QRS: None, Rate: Depends on underlying rhythm P waves: See description in PJC above. Prophecy Medical Surgical Telemetry QuizletMedical Surgical Telemetry B Flashcards. Infer why little evidence of Proterozoic orogenies exists today. Which fires first is easily detected on an ECG, premature junctional complex chest pain pulse ox at 86%. Math can be a difficult subject for many people, but it doesn't have to be! When there is no history of GERD Correct Answer: Protonix is given as G.I. Correct Answer: Morphine Duramorph, oxygen, nitrates, Aceticsalicylic acid, bayer buffered aspirin The Glasgow, scale ranges from: Correct Answer: 3 to 15 You deserve the nurse aid removing her gloves and immediately using alcohol hand sanitizer in a room with a patient who has C-Diff. He asks you about the procedure what would be the most therapeutic response? You will need to stay still in the bed during each treatment session. During the assessment, the client states, "Last week I crashed my car because my vision suddenly became blurry." prophylaxis to prevent stress ulcers Correct Answer: Normal sinus with VTach The patient has a morphine PCA post operatively. Which of the following actions should the nurse take? Low stimulation threshold can lead to non-capture due to scaring at the anchor site of the wire in the right ventricle causing increased resistance to the impulse. Inherent rate is 40-60. Study with the several resources on Docsity, Prepare for your exams with the study notes shared by other students like you on Docsity, The best documents sold by students who completed their studies, Clear up your doubts by reading the answers to questions asked by your fellow students, Earn 10 points for each uploaded document and more additional points based on the downloads get, Get download points for each document you share, Help other students and earn 10 points for each answered question, Earn Premium Points for no-holds-barred downloads of shared documents and Store documents, Connect with the world's best universities and choose your course of study, Ask the community for help and clear up your study doubts, Discover the best universities in your country according to Docsity users, Download our free guides on studying techniques, anxiety management strategies, and thesis advice from Docsity tutors, Download Prophecy medical surgical-telemetry (Latest 2022/2023) and more Nursing Exams in PDF only on Docsity! Which of the following instructions should the nurse include in the plan of care? Patterns: Bi and trigemeny, couplets and triplets. You do not speak Spanish and are having difficulty communicating with your patient. Which of the following information should the nurse include in the teaching? PRI: If P wave is present before QRS, < 0.12 sec. Your patient voids for the first time two hours after the orders received. Which of the following actions would be considered a violation of Hyppa? Correct Answer: Looking through the chart of a coworker admitted to your unit Correct Answer: Sinus tachycardia You are taking care of a patient who is admitted for left flank pain with a kidney stone of 1.5 cm. What education should you provide to. Other manifestations include nausea, vomiting, fatigue, and headache. Didn't nurse ask you about the typical signs and symptoms of myocardial infarction Which of the following issues should be reported up the chain of command Prophecy medical surgical-telemetry You are to obtain informed consent for a Spanish-speaking patient scheduled for surgery. Ongoing investment in employees makes them feel empowered and valued, and it cultivates future leaders. Which of the following statements should the nurse make? 2022 apple notes web clipper shortcut on prophecy labor and delivery rn a v1 quizlet. Loosen restrictive clothing on the client. Correct Answer: A respiratory rate of 8 breaths per minute Correct Answer: Paced rhythm Your patient was admitted with severe dehydration. You are caring for a diabetic patient admitted for uncontrolled blood sugar. Prophecy Medical Surgical Exam Answers - Orris. Which of the following images depicts a condition caused by pernicious anemia? Airborne You do not speak Spanish and are having difficulty communicating with your patient. Medical Surgical Telemetry B Flashcards | Quizlet Medical Surgical Telemetry B 3.8 (9 reviews) Term 1 / 9 The physician has ordered for your COPD patient to receive 80mg of Solu-Medrol IV every 8 hours. A nurse is caring for a client who has an arterial line. A nurse is caring for an older adult client who has dementia and requires acute care for a respiratory infection. Which of As you inflate a balloon, the patient complains of discomfort what is the best action? The nurse notes a pacemaker artifact followed by a QRS complex. (Select all that apply. Protonix is given as G. prophylaxis to prevent stress ulcers You were caring for a patient who is 18 hours postop after a right BKA a. Rhythm: P waves regular, QRSs regular but at different rates. Heart rate 52/min Increase shortness of breath Rhythm: Atrial regular, ventricular irregular d/t dropped beats P waves: May be present or absent depending on pacing settings (VVI vs DDD) Numbness can occur along the inside of the affected arm p% KEx/Jf&qWyB5@1a"'c Js\t/1NM81`4jV1p)o}^6kp2,z,o Z+ Ql]azDEHxvHh'!0>agXnv%CItoREz498[`Bz @Db[&. (Move the steps into the box on the right, placing them in the selected order of performance. HCO3 - 23. 5: Measure the QRS Complex As you inflate a balloon, the patient complains of discomfort what is the best action? P waves: Same as PVC prophecy medical surgical telemetry exam a v1 quizlet Author: Episode #4 Determine math equations Mathematical equations are a great way to test your problem-solving skills. Which of the following actions should nurse take to avoid restraining the client? You notify the following is the best nursing action? A nurse is planning care for an older adult client who has dementia. You're reviewing the menu list of a patient on Warfran what food should they not eat? Rhythm: Regular For [OH]=9.87109M\left[\mathrm{OH}^{-}\right]=9.87 \times 10^{-9} \mathrm{M}[OH]=9.87109M, calculate the pOH\mathrm{pOH}pOH of the solution as well as the concentration of hydrogen ion in the solution. -block You were caring for a patient admitted with abdominal pain. Pacemakers are programmed to initiate pacing when the heart rate falls below a certain rate. Telemetry detects the ability of cardiac cells to generate a spontaneous and repetitive electrical impulse through the heart muscle. Encourage the client to take deep breaths after the procedure A nurse is caring for a client who is receiving a blood transfusion. njcjohnson. Their patient has a sudden cardiac arrest and family wants CPR initiated. Scan the environment by turning your head from side to side.". The nurse is taking care of a patient who is terminally ill and has a DNR on file. P waves: Same as PVC The nurse should explain that applying a TENS unit to the painful area has which of the following effects? P waves: One before every QRS each large box = 0.20 seconds, 1: Determine the regularity of the rhythm. When there is no history of GERD, Protonix is given as G.I. When a pacing stimulus is delivered to the ventricle, a pacemaker artifact appears as a spike on the ECG rhythm strip. P waves: Same as PVC A nurse is preparing to administer a blood transfusion to a client who has anemia. Research the impact of amalgamation gold processing on the Amazon region of Brazil. QRS: 0.06-0.10(12), Rate: 101-180 bpm PRI: Same as PVC P waves: May not be visible due to rate. can take many shapes, VENTRICULAR DEPOLARIZATION and BEGINNING OF VENTRICULAR REPOLARIZATION Prophecy health medical surgical RN A correct Answers 2022 2023. Correct Answer: Due to the size of the kidney stone it is an appropriate treatment? each small box = 0.04 seconds not always present Which of the following findings should the nurse identify as the priority? Rhythm: Irregular, fibrillatory waves may be course or fine A coworker arriving to work under the influence of alcohol Medical Surgical Rn A Prophecy Quizlet Prophecy Medical Surgical Telemetry Exam A V1 AnswersYour patient has symptomatic anemia but is refusing a blood transfusion for religious reason. Which of the following findings should the nurse report to the provider immediately? No progressively longer pattern. Thoracentesis, the removal of pleural fluid, can temporarily relieve hypoxia and thus ease the client's breathing and improve comfort. Prophecy EKG. Prophecy Health Nurse Testing Answers - exams2020.com Medical Surgical. If the pacemaker fires just as the intrinsic impulse occurs, the two impulses "collide"; the intrinsic traveling from the AV down and the pacer spike from the apex up. Which of the following interventions should the nurse include in the plan of care? a sudden cardiac arrest and family wants CPR initiated. Which of the following resources would be most appropriate to utilize in order to obtain c. Assess your patient for a change in condition Which of the following electrolyte value should be Addressed immediately by the nurse Patient is admitted for shortness of breath. A nurse is planning discharge teaching for a client who has an external fixation device for a fracture of the lower extremity. A nurse is teaching a group of newly licensed nurses about pain management for older adult clients. QRS: 0.06-0.10(12), second degree AV block type I or morbitz I or wenchebach, Rate: Atrial rate>ventricular due to dropped QRSs End: beginning of QRS Rate: Depends on underlying rhythm Which of the following values should the nurse identify as a desired outcome for this therapy? My joints ache because I have Lyme disease, A nurse is preparing to administer phenytoin 600 mg PO daily to a client. PRI: Same as PVC Prophecy medical surgical-telemetry exam test; answered & graded A+, latest summer 2022. After ensuring a patent airway, which of the following nursing interventions is the priority? Flex the foot every hour when awake. PRI: 0.12-0.20 sec Flutter waves may be sawtooth or rounded. Mealtimes do not pertain to this client due to the NPO status. -nonconducted premature atrial contraction The degree of perpendicular can also be seen as a decrease in amplitude only. Looking through the chart of a coworker admitted to your unit. Which of the following disorders presents the greatest risk to this group of clients? Correct Answer: Aspirate the fluid, advance the catheter farther, then re-inflate the balloon When assessing a patient, you notice crepitus on the right upper shoulder. 3/11 Prophecy Health Nurse Test Answers. A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. To guide Safe and competent nursing and medical practice associated with the use of cardiac telemetry monitoring. Exam (elaborations . Which of the following actions should the nurse take first? coworker to sign for the ways that you did not witness Check for the type and number of units of blood to administer. diagnosis what should you instruct the patient to avoid? Medical Surgical-Telemetry Exam Content, Your email address will not be published. First-Degree AV Block Aspirate the fluid, advance the catheter farther, then re-inflate the balloon (Select all that apply. Undersensing occurs when the pacer does not "see" an intrinsic beat and therefore fires. Long refractory periods potentiates the risk for multifocal VT or Torsades important for doing 12 lead EKG, ST elevation, ST depression, convex (arched upward) or concave (arched downward). Correct Answer: Lipase and amylase You're caring for a 12 hour postoperative parathyroidectomy patient. Prednisone can also reduce intestinal absorption of calcium. Narcan Which of the following findings from the client's medical record should indicate to the nurse the need to withhold the medication and notify the provider? DEPOLARIZATION OF VENTRICULAR MYOCARDIUM The spike should be followed by a QRS complex, which indicates pacemaker capture or depolarization. gabbz524. The nurse should identify that which of the following client actions indicates an understanding of the teaching? QRS: > 0.12 sec. Which of the following actions should the nurse anticipate taking? Chamberlain College of Nursing. Acetylsalicylic acid ( Bauer buffered aspirin) Prophecy medical surgical-telemetry Term 1 / 60 You are to obtain informed consent for a Spanish-speaking patient scheduled for surgery. P Waves: PVCs usually have no P waves or retrograde Ps. Glucose 272 115 reads death penalty papers by students Upon initial assessment you observe a blood pressure of 90/45, heart rate of 28, and a constricted pupil. prophecy medical surgical telemetry exam a v1 quizlet Author: Episode #4. A nurse is assessing a client following the completion of hemodialysis. Heart rate As you inflate a balloon, the patient PRI: None Which of the following medication should you question? less than 300 mg/dL indicates improvement in the client's status. correct electrode placement for leads I, II, III and MCL1 or V1. Morphine Duramorph, oxygen, nitrates, Which assessment finding would indicate an emergency? Causes include wire dislodgment or a sensitivity setting that is too low. PRI: As above University of the West of England (South West). -ventricular standstill Acetylsalicylic acid ( Bauer buffered aspirin). ), Calf pain The client becomes restless, dyspneic, and has crackles noted to the lung bases. A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Your patient who was admitted 5 days ago begins to have diarrhea. Rhythm: Regular Your patient complains of not being able to urinate since 0500. At the Bundle of His A nurse is caring for a client who has terminal cancer. May be sustained or occur in burst (paroxymal ), Rate: Non-discernable PRI: >0.20 incompatible blood products and create a systemic inflammatory response. Irrigate the indwelling urinary catheter. C. Knowledge of diabetic education for: 1. and it will give you the questions you missed and your incorrect answer. -arrhythmia Transcribed image text: Medical Surgical-Telemetry A v1 Question 21 of 60 Time Remaining 41:47 You are on the old me You to the shown to what to be your FIRST Calcode SCP You were that to FASTAFF (US.ing Corporation Main Once checy Avrigt Adediche 29 tv 8 . Knowledge of contraindications related to antidiabetic medications. Rate: 41-100 bpm Usually set to pace if SA rate <60 Select only the hot spot that corresponds to your answer.). Rate: Depends on underlying rhythm Glossitis, a smooth red tongue, is also a manifestation of deficiencies in vitamin B6, zinc, niacin, or folic acid. Enhanced automaticity can also cause "ectopic" beats such as premature junctional contractions Winston-Salem State University. When caring for a patient experiencing a tonic clonic seizure, the most appropriate nursing intervention is: Protecting the patient's head and extremities from contact with surrounding objects. A nurse is caring for a client who is 4 hr postoperative following an open reduction internal fixation of the right ankle.