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. Changed mental status: Older adults often exhibit atypical signs of infection, such as confusion, agitation, or other changes in mental status, rather than classic symptoms like fever or dysuria.
B. Temperature 37.3° C (99.1° F): This temperature is within normal range and does not indicate an infection. Older adults may not always mount a fever with infections.
C. WBC count 9,000/mm³ (5,000 to 10,000/mm³): This is within the normal range, so it does not suggest infection. An elevated WBC count (>10,000/mm³) may indicate an infection.
D. Diminished reflexes: This is not a symptom of a bladder infection. It is more commonly associated with neurological or musculoskeletal conditions.

A. Restrict visitors to family members until the client is able to wear a prosthesis. B. Encourage the client to talk with another client who completed rehabilitation for amputation. C. Instruct the client to ignore phantom pain sensations. D. Suggest that family members bring clothing for the client from home. E. Ask the client to describe her feelings about the loss of the affected limb.

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

Explanation

A. Restrict visitors to family members until the client is able to wear a prosthesis: Restricting visitors may increase isolation and hinder emotional support.
B. Encourage the client to talk with another client who completed rehabilitation for amputation: Peer support can provide emotional reassurance and motivate the client in their recovery process.
C. Instruct the client to ignore phantom pain sensations: Phantom pain is real and should not be dismissed; it requires management through medication or other interventions.
D. Suggest that family members bring clothing for the client from home: Familiar clothing can improve self-esteem and promote adjustment to body image changes.
E. Ask the client to describe her feelings about the loss of the affected limb: Exploring the client’s feelings helps address emotional and psychological aspects of coping with amputation.

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection?

Correct Answer is A

Explanation

A nurse at a rehabilitation facility is contributing to the plan of care for a client who has had a below-the-knee amputation. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

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

Explanation

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