A client with a fracture of the left arm that has been set in a cast complains of severe, diffuse pain that is unrelieved by pain medication. The nurse notes that the pulse distal to the site of injury has weakened and that the tissue is pale. Which of the following nursing actions should the nurse perform first?

Contact the health care provider.

Administer PRN pain medication.

Document the findings.

Elevate the extremity.

Answer and Explanation

The Correct Answer is A

Choice A Reason: Contacting the health care provider is the first nursing action that the nurse should perform, as it indicates that the client may have compartment syndrome, which is a medical emergency that requires immediate intervention to prevent tissue necrosis and nerve damage.

Choice B Reason: Administering PRN pain medication is not the first nursing action that the nurse should perform, as it may not relieve the pain and may mask the symptoms of compartment syndrome.

Choice C Reason: Documenting the findings is not the first nursing action that the nurse should perform, as it may delay the treatment and worsen the outcome of compartment syndrome.

Choice D Reason: Elevating the extremity is not the first nursing action that the nurse should perform, as it may decrease blood flow and increase tissue ischemia in compartment syndrome.

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Correct Answer is C

Explanation

Choice A Reason: Cushing's is not an expected health problem in a client with high potassium level, as it causes low potassium level due to excess cortisol and aldosterone production.

Choice B Reason: Diabetes insipidus is not an expected health problem in a client with high potassium level, as it causes low potassium level due to excessive water loss and dilution of blood.

Choice C Reason: Addison's is an expected health problem in a client with high potassium level, as it causes high potassium level due to insufficient cortisol and aldosterone production.

Choice D Reason: Diarrhea is not an expected health problem in a client with high potassium level, as it causes low potassium level due to excessive fluid and electrolyte loss.

A. Cloudy urine B. Muscle tetany C. Presence of calculi D. Urinary frequency E. Dysuria

Correct Answer is ["A","D","E"]

Explanation

Choice A Reason: Cloudy urine is a finding that indicates a urinary tract infection, as it shows that there are bacteria, pus, or blood in the urine.

Choice B Reason: Muscle tetany is not a finding that indicates a urinary tract infection, but it may indicate other conditions such as hypocalcemia or alkalosis.

Choice C Reason: Presence of calculi is not a finding that indicates a urinary tract infection, but it may cause or complicate a urinary tract infection by obstructing the urine flow and creating a nidus for bacterial growth.

Choice D Reason: Urinary frequency is a finding that indicates a urinary tract infection, as it shows that there is irritation and inflammation of the bladder and urethra.

Choice E Reason: Dysuria is a finding that indicates a urinary tract infection, as it shows that there is pain or burning sensation during urination.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse notes that a client's serum potassium level is 6 mEq/L. The nurse interprets this as an expected finding in the client with which health problem?

Correct Answer is C

Explanation

A nurse is collecting data from a client who has a urinary tract infection. Which of the following findings should the nurse expect? Select all that apply.

Correct Answer is ["A","D","E"]

Explanation

A nurse is reinforcing teaching about TNM staging with a client who has cancer. Which of the following information should the nurse include in the teaching?

A nurse is caring for a client with myasthenia gravis who is exhibiting signs of cholinergic crisis. Which medication does the nurse ensure is available to treat this crisis?

A nurse is collecting data from a client diagnosed with laryngeal cancer who is postoperative following a laryngectomy. Which of the following is a clinical manifestation of a hemorrhage?

A nurse is caring for a client who has benign prostatic hyperplasia (BPH). Which of the following findings should the nurse expect?

The nurse is caring for a client after a total thyroidectomy. The nurse's priority should be to:

The nurse is caring for a client who has a fractured tibia and is in a cast. Which of the following findings is a manifestation of compartment syndrome?

A nurse is planning to reinforce teaching with a client who has hemorrhoids. Which of the following information should the nurse plan to include in the instructions?