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A 68-year-old male patient, who had bilateral total hip arthroplasty two years ago, arrived at the emergency department by ambulance.
He reports that he slipped while putting away groceries at home.
He did not feel dizzy or lightheaded before the fall.
He fell face-forward, hitting his head on the wall and his left shoulder on the floor.
He reports pain mainly in his left shoulder.
As a nurse, what interventions should you plan to reduce further complications?

Administer morphine as prescribed.

Monitor the patient’s vital signs.

Apply a cold pack to the affected area.

Arrange for an X-ray of the left shoulder.

Answer and Explanation

Correct Answer : A,B,C,D

Choice A rationale

Administering morphine as prescribed would help to manage the patient’s reported pain.

Choice B rationale

Monitoring the patient’s vital signs is crucial in assessing the patient’s physiological response to the fall and ensuring stability.

Choice C rationale

Applying a cold pack to the affected area can help to reduce swelling and alleviate pain.

Choice D rationale

Arranging for an X-ray of the left shoulder would help to identify any potential fractures or other injuries resulting from the fall.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["A","B","C"]

Explanation

Based on the provided information, the following notations require immediate follow-up:

Boggy fundus 1 cm above the umbilicus: A boggy (soft) fundus can indicate uterine atony, a condition in which the uterus fails to contract after delivery. This can lead to postpartum hemorrhage, a serious and potentially life-threatening condition.
Fundus rotated to the right: A displaced fundus can be a sign of a distended bladder, which can interfere with uterine contraction and lead to postpartum hemorrhage.
Blood pressure: 90/62 mm Hg: While this blood pressure isn’t extremely low, it is on the lower end of normal. Given the potential for postpartum hemorrhage indicated by the other findings, this should be monitored closely.

A. Hematocrit. B. Neutrophil count. C. Platelet count. D. Serum sodium level.

Correct Answer is B

Explanation

Choice A rationale

Hematocrit is a measure of the proportion of red blood cells in the blood. While it can be affected by various conditions, it is not the most relevant lab value to check when purulent drainage is noticed at a postoperative patient’s dressing site.

Choice B rationale

Neutrophil count is a measure of the number of neutrophils, a type of white blood cell, in the blood. An elevated neutrophil count can indicate an infection, making it the most relevant lab value to check in this scenario.

Choice C rationale

Platelet count is a measure of the number of platelets in the blood. While platelets play a crucial role in blood clotting, they are not directly related to infection and therefore not the most relevant lab value to check in this scenario.

Choice D rationale

Serum sodium level is a measure of the amount of sodium in the blood. While it can be affected by various conditions, it is not the most relevant lab value to check when purulent drainage is noticed at a postoperative patient’s dressing site.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C"]

Explanation

While changing a postoperative patient’s dressing, the nurse notices purulent drainage at the site.Before reporting this to the healthcare provider, which of the patient’s lab values should the nurse check?

Correct Answer is B

Explanation

Which client statements require follow-up teaching by the nurse? Select all that apply.

A patient with primary hypothyroidism is showing early signs of myxedema coma. In what order should the nurse perform the following assessments? (Rank the first action at the top with the remainder in descending order.)

A straight catheter produced 500 mL of clear yellow urine. For each finding, indicate whether the findings suggest that the client’s condition has improved or put the client at risk for hypovolemia. Each column must have at least one selection.

The nurse is conducting a functional assessment on an older patient who has lost five pounds (2.27 Kg) since the last visit 12 weeks ago and reports a decrease in energy and appetite.Which action should the nurse include during the assessment?

A client admitted with pneumonia and on bedrest has not had the strength to perform self-care.Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?

A patient taking temazepam informs you, the nurse, of plans to quit taking the medication due to feelings of being “hungover” the next day.What action should you implement?