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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Pernicious anemia is a type of anemia that occurs due to a lack of intrinsic factor, a protein necessary for the absorption of vitamin B12 (cobalamin) in the digestive system. As a result, patients with pernicious anemia are unable to absorb sufficient amounts of vitamin B12 from dietary sources. The treatment for pernicious anemia involves regular administration of cobalamin (B12) injections to bypass the impaired absorption and provide the necessary vitamin B12 directly.

Oral ferrous sulfate tablets are not the appropriate treatment for pernicious anemia. Ferrous sulfate is a form of iron supplement used to treat iron deficiency anemia, which is different from pernicious anemia.

Iron dextran infusions are also not indicated for pernicious anemia. Iron dextran is used for iron replacement therapy in cases of iron deficiency anemia, but it does not address the underlying issue of vitamin B12 deficiency in pernicious anemia.

Routine blood transfusions may be necessary in some cases of pernicious anemia, especially if the patient is severely anemic. However, the primary treatment for pernicious anemia is cobalamin (B12) injections, which provide the necessary vitamin B12 that the patient is unable to absorb.

A. Asking for nausea B. Evaluating for sacral redness C. Checking the respiratory rate D. Auscultating bowel sounds

Correct Answer is C

Explanation

Morphine is a potent opioid analgesic that can depress the respiratory system. Respiratory depression is a potential adverse effect of morphine, and it is essential for the nurse to monitor the patient's respiratory rate regularly to ensure adequate oxygenation and prevent respiratory complications.

By checking the respiratory rate, the nurse can assess if the patient is breathing adequately and detect any signs of respiratory depression. If the respiratory rate is significantly decreased or the patient shows signs of respiratory distress (e.g., shallow or irregular breathing), immediate intervention is necessary to address the situation promptly.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse will plan to teach a patient who has pernicious anemia about the need for:

Correct Answer is B

Explanation

The nurse is caring for a patient who had abdominal surgery yesterday and is receiving morphine through patient controlled analgesia (PCA). What action by the nurse is a priority?

Correct Answer is C

Explanation

In replying to a client's questions about the seriousness of the chronic kidney disease (CKD), the nurse knows that the stage of CKD is based on what?

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?

After the insertion of an arteriovenous graft (AVG) in the right forearm, a patient complains of pain and coldness of the right fingers. Which action should the nurse take?

A school nurse is performing screening examinations for scoliosis. Which signs of scoliosis should the nurse assess for?

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?

An older adult client fell while getting out of bed. Which assessment finding indicates a possible hip fracture?

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?