A nurse is assisting with the care of a client on an orthopedic unit.

Exhibits

Select words from the choices below to fill in each blank in the following sentence.

The client is at risk for developing
dropdown
.

Answer and Explanation

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

The correct answer is choice A: Fat embolism syndrome.

Choice A rationale:

The client with an open fracture to the right femur is at risk for developing Fat Embolism Syndrome (FES) FES occurs when fat globules from the bone marrow or other tissues enter the bloodstream, leading to systemic complications. In this case, with an open fracture, there is a higher risk of fat emboli entering the circulation. The clinical manifestations of FES include respiratory distress, altered mental status, and petechial rash. These symptoms typically occur within 24-72 hours after the injury, which aligns with the timeline mentioned in the progress report on Day 1 of admission.

Choice B rationale:

Osteomyelitis is less likely to develop within the first 24 hours following a motor vehicle crash. It is an infection of the bone and typically takes more time to manifest. The early concerns in an open fracture involve the risk of infection, but osteomyelitis is not an immediate threat in this scenario.

Choice C rationale:

Compartment syndrome is a potential concern in orthopedic injuries, but it primarily arises due to increased pressure within a muscle compartment, causing reduced blood flow. While it is a valid concern, it is not typically associated with fat embolism syndrome, which is more specific to the release of fat globules into the bloodstream.

Choice D rationale:

Deep vein thrombosis (DVT) is a concern in immobile patients or those with significant trauma, but it is not the most immediate concern in this case. DVT usually develops over time and is more associated with prolonged immobilization rather than the early stages of admission.

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Correct Answer is C

Explanation

Choice A rationale:

Inquiring about a family history of suicide is relevant but not the priority when a client is actively expressing suicidal ideations. Assessing the client's immediate risk and intent is more critical.

Choice B rationale:

Understanding the stresses in the client's life is important, but asking about a plan for self-harm takes precedence in assessing the client's immediate danger.

Choice C rationale:

This question directly addresses the client's intent and plan for self-harm. Identifying a plan is crucial in assessing the level of risk and determining the appropriate intervention.

Choice D rationale:

While having someone to discuss feelings with is important, it is not the primary concern when a client is expressing suicidal ideations. Assessing the client's immediate risk and plan for self-harm should come first.

A. Elevate the head of the client's bed for 1 hr after the feeding. B. Administer the feeding solution at a cold temperature. C. Rotate the jejunostomy tube once per day. D. Flush the tube with 90 mL of sterile water before and after the feeding.

Correct Answer is A

Explanation

Choice A rationale:

Elevating the head of the client's bed for 1 hour after the feeding is the correct choice because it helps reduce the risk of aspiration. Elevating the head of the bed at a 30-45 degree angle can promote the flow of enteral feeding solution into the jejunum, reducing the risk of reflux into the stomach and subsequent aspiration.

Choice B rationale:

Administering the feeding solution at a cold temperature is not recommended. Enteral feedings should be given at or near room temperature to prevent discomfort and cramping in the client.

Choice C rationale:

Rotating the jejunostomy tube once per day is not a standard practice. The tube should be secured in place to prevent dislodgement, but routine rotation is not necessary.

Choice D rationale:

Flushing the tube with 90 mL of sterile water before and after the feeding is not necessary for intermittent bolus enteral feedings. Flushing before and after continuous feedings may be required to maintain patency, but for intermittent bolus feedings, it is not a routine practice.

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A nurse is assisting with the care of a client on an orthopedic unit. Exhibits Select words from the choices below to fill in each blank in the following sentence. The client is at risk for developing dropdown.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is expressing suicidal ideations.Which of the following questions is the nurse's priority?

Correct Answer is C

Explanation

A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube.Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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A nurse is reinforcing teaching with a client who has GERD and a prescription for pantoprazole. Which of the following statements indicates an understanding of the teaching?

A nurse is reviewing the medical record of a client who has a new prescription for cefaclor.Which of the following findings in the client's history should the nurse report to the provider?

A nurse is assisting with the care of a client on an orthopedic unit.

Exhibits

Select words from the choices below to fill in each blank in the following sentence.

The client is at risk for developing
dropdown
.