A nurse is assisting with the care of a client on an orthopedic unit.
Select words from the choices below to fill in each blank in the following sentence.
The client is at risk for developing
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A boggy fundus 3 fingerbreadths above the umbilicus is not an expected finding after receiving oxytocin for excessive vaginal bleeding. This finding could indicate uterine atony, which is a concern, but it is not a typical immediate response to oxytocin.
Choice B rationale:
The client reporting uterine cramping is an expected finding after receiving oxytocin. Oxytocin is often administered to stimulate uterine contractions and reduce bleeding, so uterine cramping is a positive response to the medication.
Choice C rationale:
Saturation of perineal pad in 15 minutes is not an expected finding after receiving oxytocin. Excessive bleeding would be a concern, and the nurse should monitor for signs of hemorrhage.
Choice D rationale:
The client reporting burning with urination is not an expected finding related to oxytocin administration. This symptom could be indicative of a urinary tract infection or another issue unrelated to oxytocin. It should be assessed and addressed separately.
Correct Answer is ["B","C","D","E","F","G"]
Explanation
Choice A rationale:
Performing a vaginal examination every 12 hours is not necessary in this case. The client is not in labor and there are no indications of any complications that would require frequent vaginal examinations.
Choice B rationale:
The client’s symptoms of severe headache, +3 pitting edema in bilateral lower extremities, and a patellar reflex of 4+ without the presence of clonus are indicative of severe preeclampsia. Antihypertensive medications are often used to manage high blood pressure in preeclampsia.
Choice C rationale:
Betamethasone is a corticosteroid that is given to pregnant women who are at risk of delivering prematurely to help mature the baby’s lungs. Given that the client is at 31 weeks of gestation and has had a previous preterm birth, administering betamethasone would be appropriate.
Choice D rationale:
A low-stimulation environment can help reduce blood pressure and prevent seizures in clients with preeclampsia.
Choice E rationale:
Bed rest can help lower blood pressure and improve blood flow to the placenta, which can be beneficial for the baby.
Choice F rationale:
Monitoring intake and output every hour can help assess kidney function, which can be affected by preeclampsia.
Choice G rationale:
A 24-hour urine specimen can provide information about protein levels in the urine, which can indicate the severity of preeclampsia. It’s important to note that normal ranges for lab parameters can vary slightly depending on the lab, but generally, protein levels in a 24-hour urine specimen should be less than 300 mg. Pitting edema is usually graded on a scale of 1+ (mild) to 4+ (severe), and a patellar reflex of 4+ is considered hyperactive and may indicate nervous system hyperexcitability seen in severe preeclampsia or eclampsia.
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