A client sustained a left femur fracture 3 hours ago. Initial vital signs and assessment were within normal limits with the exception of left leg pain.

The nurse re-assesses the client and documents the following:

Temp: 37.2 C Pain: 7/10-chest 5/10 left leg.

Pulse: 110 bpm

Respirations: 40 breaths per min, labored 02 saturation: 88%

Neuro: A&O x 3. Anxious Skin: Petechiae to neck and anterior chest.

Based on this assessment, which action is appropriate at this time?

Notify the healthcare provider that the client's pain is not well-managed

Reassure the client that the pain and stress of the fracture will soon get better.

Order a chest CT Computerized Tomography) to rule out a pulmonary embolus (PE).

Notify the healthcare provider that the client may have a fat embolism

Answer and Explanation

The Correct Answer is D

Fat embolism syndrome can occur when fat globules enter the bloodstream after a long bone fracture, such as a femur fracture. The fat globules can travel to the lungs and cause respiratory distress and decreased oxygen saturation. The symptoms observed in the client, including tachypnea (labored breathing), decreased oxygen saturation (88%), and the presence of petechiae (small red or purple spots) on the neck and anterior chest, are consistent with fat embolism syndrome.

Fat embolism syndrome is a serious condition that requires immediate medical attention. Notifying the healthcare provider allows for prompt evaluation, confirmation of the diagnosis, and initiation of appropriate treatment. This may involve further diagnostic tests such as a chest CT scan, as mentioned in one of the options, to rule out other potential causes or complications.

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Correct Answer is B

Explanation

A paralytic ileus is a type of bowel obstruction characterized by the impairment or absence of normal bowel motility. It occurs due to the temporary paralysis or dysfunction of the muscles that propel food and waste material through the intestines. After surgery, paralytic ileus can occur as a result of the handling of the intestines during the procedure, the effects of anesthesia, or the body's response to inflammation and trauma.

The absence of bowel sounds is a key indicator of paralytic ileus. Normally, bowel sounds are present and indicate the movement of contents through the intestines. However, in a paralytic ileus, the bowel sounds may be diminished or absent due to the lack of peristalsis (wave-like contractions that move food along the digestive tract).

A. The 24-hour oral intake is 600 ml greater than the total output. B. The patient's temperature is 100.3" F 137.9" C). C. The patient reports abdominal pain at level 6 (0 to 10 scale) when ambulating D. The patient's calf is swollen, warm, and painful.

Correct Answer is D

Explanation

These symptoms suggest the possibility of deep vein thrombosis (DVT), which is a potentially serious complication following surgery. DVT occurs when a blood clot forms in a deep vein, commonly in the lower extremities. The symptoms of a swollen, warm, and painful calf can indicate the presence of a DVT.

DVT is a medical emergency that requires immediate attention and intervention to prevent further complications such as a pulmonary embolism (where the blood clot travels to the lungs). Prompt evaluation and treatment, such as anticoagulant therapy, are necessary to prevent complications

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client had surgery yesterday and is reporting abdominal discomfort and lack of appetite. The nurse auscultates the abdomen and does not detect bowel sounds. The nurse suspected which type of bowel obstruction?

Correct Answer is B

Explanation

The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider?

Correct Answer is D

Explanation

Antacids will help reduce the heart burn symptoms associated with gastro-esophageal reflux by ...

The nurse is preparing to witness the patient signing the operative consent form when the patient says, "I don't understand what the doctor said about the surgery." Which action should the nurse take next?

Therapeutic management for an adolescent with Crohn's Disease includes which treatment?

During the first few days after surgery for cleft lip, which intervention should the nurse implement?

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The nurse is administering nitroprusside by IV infusion for a client in hypertensive emergency. The nurse knows that the primary assessment will be:

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