A client reports pain worsening in their right forearm, rating the pain as 7 on a scale of 0 to 10. The client also states their right hand is "tingly.”. The client is able to move their fingers.
The client is avoiding eye contact with staff and is more withdrawn.
The client's adult child is at the bedside.
The client appears drowsy and less alert, but is oriented to person, place, time, and situation.
The client's apical pulse is regular, and their lungs are clear to auscultation.
A report is given to the operating room nurse, and the client is en route to the surgical suite via gurney for repair of a right radial fracture.
Encourage the client to ambulate to the bathroom.
Check the client's peripheral pulses and capillary refill.
Elevate the client's arm above the level of the heart.
Administer a sedative to help the client relax.
The Correct Answer is B
Choice A rationale
Encouraging the client to ambulate to the bathroom would be inappropriate and potentially harmful. The client is experiencing worsening pain, tingling, and is on a gurney en route to surgery for a fractured radius. Ambulation could exacerbate the injury, increase pain, and risk further complications. Mobility should be restricted until the fracture is stabilized and the client is post-operative.
Choice B rationale
This is the correct action as it assesses for potential complications of compartment syndrome, a critical and urgent condition. The worsening pain and tingling are classic symptoms. Compartment syndrome occurs when pressure builds within the fascial compartments, compromising circulation. A loss of peripheral pulses and delayed capillary refill are late signs of impaired circulation and are key indicators for this limb-threatening emergency.
Choice C rationale
Elevating the arm above the heart would decrease arterial blood flow to the injured extremity, which could worsen tissue perfusion and potentially lead to ischemia. For a client with a suspected circulatory compromise, such as with compartment syndrome, the arm should be kept at the level of the heart to maintain adequate blood flow.
Choice D rationale
Administering a sedative could mask the client's symptoms, particularly the level of pain and changes in mental status, which are crucial indicators of their deteriorating condition. The client's pain is a vital sign that needs to be continuously monitored, and sedation would hinder the nurse's ability to accurately assess for changes in their neurovascular status. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Documentation of admission data should occur as soon as possible after the information is obtained. Waiting until the end of the shift to chart a summary increases the risk of forgetting critical details and delays the communication of important findings to the rest of the healthcare team.
Choice B rationale: The Patient Self-Determination Act requires healthcare facilities to ask clients upon admission if they have advance directives, such as a living will or a durable power of attorney for healthcare. This information must be clearly documented in the medical record to ensure the client's end-of-life wishes are respected.
Choice C rationale: The nursing process begins with assessment, not evaluation. Evaluation is the final step where the nurse determines if goals were met. Charting should follow the chronological order of the nursing process: assessment, diagnosis, planning, implementation, and finally, evaluation.
Choice D rationale: Registered nurses are responsible for the initial admission assessment, which includes the first set of vital signs. While assistive personnel can take routine vitals later, the nurse should personally obtain and document the baseline admission data to ensure accuracy and clinical oversight.
Correct Answer is A
Explanation
Choice A rationale
A sliding hiatal hernia occurs when the gastroesophageal junction and a portion of the stomach slide up into the chest through the diaphragm's esophageal hiatus. This displacement disrupts the lower esophageal sphincter's function, causing gastric acid to reflux into the esophagus and resulting in heartburn.
Choice B rationale
Abdominal cramping is typically associated with conditions affecting the intestines, such as irritable bowel syndrome, inflammatory bowel disease, or bowel obstruction. It is not a direct symptom of a sliding hiatal hernia, which primarily affects the stomach and esophagus.
Choice C rationale
Breathlessness or dyspnea can be a symptom of a very large hiatal hernia that compresses the lungs. However, for a standard sliding hiatal hernia, it is not a primary or expected finding. The most common manifestation is related to acid reflux.
Choice D rationale
Constipation is a condition of the large intestine and is characterized by infrequent bowel movements. It is not directly caused by a sliding hiatal hernia, as the hernia’s primary impact is on the stomach and esophagus, causing upper gastrointestinal symptoms. *.
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