A nurse is assisting with the care of a newly-admited client who has acute osteomyelitis. Which of the following interventions is the priority for the nurse to implement?

Optimal nutrition and hydration

Surgical debridement of necrotic tissue

Antibiotic therapy

Antipyretic therapy

Answer and Explanation

The Correct Answer is C

The priority intervention for the nurse to implement for a newly-admitted client who has acute osteomyelitis is antibiotic therapy. Osteomyelitis is an inﬂammatory condition of bone secondary to an infectious process¹. Antibiotics are the primary treatment option and should be tailored based on culture results and individual patient factors.

a. Optimal nutrition and hydration is important but not the priority intervention.
b. Surgical debridement of necrotic tissue may be necessary but is not the priority intervention.
d. Antipyretic therapy may be necessary but is not the priority intervention.

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Correct Answer is A

Explanation

The first action the nurse should take is to check the client for injuries. The nurse should assess the client for any signs of injury or trauma and provide appropriate care as needed.

Obtaining a prescription for medication to sedate the client, calling the family and asking them to make arrangements for someone to sit with the client, and assisting the client back into bed and applying restraints are not appropriate initial actions for the nurse to take in this situation. These actions may be considered after the client has been assessed for injuries and their immediate needs have been addressed.

A. Monitor for elevated blood pressure. B. Provide analgesia for headaches. C. Prevent bladder distention. D. Elevate the client's head.

Correct Answer is C

Explanation

To prevent autonomic dysreﬂexia, the nurse should take the intervention of preventing bladder distention. Autonomic dysreﬂexia is a serious medical problem that can happen if a person has injured the spinal cord in their upper back¹. It makes their blood pressure dangerously high and can lead to a stroke, seizure, or cardiac arrest¹. One way to lower the chance of complications is to use the bathroom on a regular schedule and keep the bladder and bowels from becoming too full.

a. Monitoring for elevated blood pressure is important but not an intervention to prevent autonomic dysreﬂexia.
b. Providing analgesia for headaches is important but not an intervention to prevent autonomic dysreﬂexia.
d. Elevating the client's head is important but not an intervention to prevent autonomic dysreﬂexia.

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A nurse is assisting with the care of a newly-admited client who has acute osteomyelitis. Which of the following interventions is the priority for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility finds an older adult client lying on the ﬂoor next to the bed. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreﬂexia. Which of the following interventions should the nurse take to prevent autonomic dysreﬂexia?

Correct Answer is C

Explanation

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