A nurse in the emergency department is caring for a client who has a compression fracture of a spinal vertebra. During transport to the facility. the client was medicated with intravenous morphine. On arrival, the neurosurgeon determined urgent surgical intervention is indicated for the fracture. Staff members have been unable to reach the client's family. Which of the following actions should the nurse anticipate the neurosurgeon taking?

Delaying the surgery until a member of the client's family is reached

Prescribing naloxone to reverse the effects of the morphine

Invoking implied consent

Asking the client to sign the surgical consent form

Answer and Explanation

The Correct Answer is C

A. Delaying the surgery until a member of the client's family is reached may not be in the best interest of the client if urgent surgical intervention is indicated.

B. While naloxone can reverse the effects of opioids like morphine, it is not the primary action the neurosurgeon would take in this situation. The priority is addressing the urgent surgical need.

C. Invoking implied consent is the most appropriate action in this situation. Implied consent is assumed in emergency situations where the client is unable to provide consent, and delay would significantly jeopardize the client's health.

D. Asking the client to sign the surgical consent form would not be feasible in this situation since the client is likely not in a condition to provide informed consent due to the administration of intravenous morphine and the urgency of the surgical intervention.

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Correct Answer is C

Explanation

A. Mild erythema (redness) at the pin sites can be a normal finding due to the body's response to the presence of foreign objects. It may not necessarily indicate infection.

B. Serosanguineous drainage (a mixture of clear and bloody fluid) can also be a normal finding initially after the insertion of pins. It may not necessarily indicate infection.

C. Fever is a systemic response to infection. In a client with skeletal traction, fever can be an indication of an infection at the pin sites or a more systemic infection related to the traction device.

D. Warmth around the pin sites can be a normal finding due to the inflammatory response that occurs after pin insertion. It may not necessarily indicate infection.

Correct Answer is ["63"]

Explanation

- To calculate the gtt/min, use the formula: gtt/min = (volume in mL x drop factor in gtt/mL) / time in min

- Substitute the given values: gtt/min = (250 mL x 15 gtt/mL) / 60 min - Simplify and round: gtt/min = 62.5 gtt/min ≈ 63 gtt/min

- The nurse should set the manual IV infusion to deliver 63 gtt/min

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites?

Correct Answer is C

Explanation

Correct Answer is ["63"]

Explanation

A nurse is caring for a client who is postoperative following a laminectomy with spinal fusion. Which of the following actions should the nurse take?

A nurse assessing a client who has multiple fractures in his left leg notes increasing edema. The nurse should recognize this finding as an early manifestation of which of the following complications?

A nurse is caring for a client who has a new short-leg cast on his lower leg to treat an ankle fracture. Which of the following findings requires immediate notification of the provider?

A nurse is caring for a client who has a fractured tibia as a result of a fall. The client's x-ray shows that the bone is splintered into several pieces around the shaft. The nurse should identify that the client has which of the following types of fractures?

A nurse at an urgent care center is caring for four clients who all have leg or foot injuries. Which of the following client reports should suggest to the nurse that the client has an ankle sprain?

A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. Which of the following instructions should the nurse include?