A nurse is assisting in the care of a client whoThe first action the nurse should take is to followed by. is postoperative following an open reduction internal fixation of the right tibia.

Exhibits

Complete the following sentence by using the lists of options.

The first action the nurse should take is to
dropdown
followed by
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

The first action the nurse should take is to assess neurovascular status followed by notify the provider.

Assess neurovascular status first: The diminished pulses and coolness of the right foot indicate compromised circulation, requiring immediate evaluation to confirm the severity.
Notify the provider: Once the critical assessment findings are confirmed, notifying the provider for prompt intervention is essential to prevent further complications.

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Correct Answer is A

Explanation

A. Perform suctioning: Restlessness and crackles in the lungs may indicate retained secretions. Suctioning the tracheostomy can help clear secretions and improve oxygenation.
B. Instill saline into the tubing: Routine instillation of saline is not recommended as it can cause discomfort, dislodge bacteria, or create a risk of aspiration.
C. Increase the humidification: While humidification helps prevent mucus from becoming thick, it does not address the immediate issue of retained secretions causing crackles.
D. Check the cuff pressure: While it is important to ensure appropriate cuff pressure, this is not the primary intervention for resolving restlessness and crackles, which suggest secretion buildup.

A. Findings of right lower extremity assessment B. Pain level C. Level of consciousness D. Oxygen saturation E. Right pedal pulses F. Temperature G. X-ray results

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

Explanation

A. Findings of right lower extremity assessment: The diminished pulses, cool temperature, and reduced sensation of the right foot suggest impaired circulation and potential compartment syndrome, which is an emergency.
B. Pain level: A pain level of 10/10 that is disproportionate to the injury indicates a need for immediate evaluation, as it may signal compartment syndrome.
C. Level of consciousness: Not concerning as the client is alert and denies loss of consciousness.
D. Oxygen saturation: Normal at 97%.
E. Right pedal pulses: A diminished pedal pulse (1+) on the right is a critical finding that requires urgent intervention to restore circulation.
F. Temperature: A temperature of 36°C is within normal limits and does not require follow-up.
G. X-ray results: Confirms the fracture but is not a finding requiring immediate follow-up compared to circulatory concerns.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a tracheostomy tube. Upon data collection, the nurse observes the client is restless and hears crackles in the lungs. Which of the following interventions should the nurse take?

Correct Answer is A

Explanation

A nurse is assisting in the care of a client who is in the emergency department (ED) following a ski accident. Exhibits The nurse is collecting data on the client. Which of the following findings require follow up? Select all that apply.

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

Explanation

A nurse in an assisted living facility is collecting data from an older adult client who fell in their room and hit their head on the dresser. Which of the following findings is the nurse's priority?

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A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result?

Exhibits Which of the following actions should the nurse assist with? (Click on the exhibit tabs for additional information about the client.)

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A nurse is collecting data from a client who underwent a thyroidectomy 4 hr ago. Which of the following client findings indicates a complication of the procedure?

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