Answer:
The client traction weights are resting on the floor.
Explanation:
The immediate action of the nurse should be to reapply the weights to give traction to the fracture. The health care provider must be notified that the weights were lying on the floor, and the client should be realigned in bed. The client's blood pressure is slightly elevated; this could be related to pain and muscle spasms resulting from lack of pressure to reduce the fracture. Oozing of clear fluid is normal, as is the capillary refill time.
DIF: Applying/Application REF: 1060 KEY: Fracture| traction
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
Answer:
b. pass through pores in the capillary endothelium
Explanation:
The fenestrated capillaries and sinusoids have pores in their endothelium. These pores or the intracellular clefts vary in size between the fenestrated capillaries and sinusoids. Sinusoids have larger intracellular clefts. The pores serve as a passage for the movement of water-soluble substances, proteins and other substances that cannot cross the hydrophobic interior of the cell membranes.
Water-soluble hormones also cannot pass through the capillary walls. Therefore, these hormones pass through the pore or the fenestrations present in the endothelium of capillaries.
