A nurse is assisting with the care of an adolescent.

Exhibits

Complete the following sentence by using the lists of options.

The adolescent is at risk for developing
dropdown
evidenced by
dropdown

Answer and Explanation

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

Rationale for Correct Options:

Compartment syndrome is a serious complication that can occur after a fracture, particularly of a long bone like the femur. It results from increased pressure within a muscle compartment, leading to decreased blood flow and potential tissue damage.

Edema of the toes suggests swelling, which may indicate increasing pressure within the affected limb. The adolescent is already reporting significant pain (7/10) and has required repeated doses of IV morphine, which may not be sufficient to relieve compartment syndrome pain (a key warning sign). If left untreated, compartment syndrome can cause nerve and muscle damage, ischemia, and even permanent disability.

Rationale for Incorrect Options:

Deep Vein Thrombosis (DVT): DVT is a risk with immobilization, but it usually presents with unilateral swelling, warmth, and pain in the affected limb, not just toe edema.

Fat Embolism Syndrome: This occurs due to fat globules entering circulation after a long bone fracture. Symptoms include respiratory distress, mental status changes, and petechiae, which are not present here.

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Correct Answer is A

Explanation

A. Raises all four side-rails on the client's bed. Raising all four side-rails can create a risk for falls, as it may lead to a false sense of security and prevent the client from being able to exit the bed safely if needed. Additionally, it can increase the risk of entrapment or injury. The recommended practice is to keep two side-rails up while allowing for easy access and mobility for the client.
B. Locks the wheels on the client's bed. Locking the wheels on the client's bed is an appropriate action. This prevents the bed from rolling and helps ensure the client's safety, particularly when they are getting in and out of bed or during care activities.
C. Assists the client to the bathroom every 2 hr. Assisting the client to the bathroom every 2 hours is a reasonable intervention for a client at risk for falls, as it promotes regular toileting and prevents the need for urgent trips to the bathroom that could increase the risk of falling.
D. Clears furniture from the path leading to the bathroom. Clearing furniture from the path leading to the bathroom is a proactive safety measure. This reduces obstacles and hazards, promoting a safer environment for the client and minimizing the risk of falls during ambulation.

A. Occasional small clots in the urine B. Frequent urge to urinate C. Dark red urine D. Urine output of 300 mL over 8 hr

Correct Answer is C

Explanation

A. "Occasional small clots in the urine." Small clots in the urine can be expected in the first 24 to 48 hours following a vaginal hysterectomy due to minor bleeding from surgical manipulation. However, large or persistent clots should be reported as they may indicate active bleeding.
B. "Frequent urge to urinate." A frequent urge to urinate is common after surgery due to bladder irritation, inflammation, or the effects of anesthesia. However, if accompanied by pain, burning, or difficulty urinating, it could indicate a urinary tract infection or urinary retention requiring further evaluation.
C. "Dark red urine." Dark red urine suggests active bleeding, which is not an expected postoperative finding and requires immediate evaluation. This may indicate excessive surgical site bleeding or trauma to the urinary tract, necessitating prompt intervention by the provider.
D. "Urine output of 300 mL over 8 hr." While this is lower than the expected urine output (at least 30 mL/hr or 240 mL in 8 hours), it is not critically low. The nurse should encourage fluid intake and monitor for signs of dehydration or urinary retention before escalating the concern to the provider.

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A nurse is assisting with the care of an adolescent. Exhibits Complete the following sentence by using the lists of options. The adolescent is at risk for developing dropdownevidenced bydropdown

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is supervising an assistive personnel (AP) who is caring for a client who is at risk for falls. For which of the following actions by the AP should the nurse intervene?

Correct Answer is A

Explanation

A nurse is collecting data from a client who is 1 day postoperative following a vaginal hysterectomy. Which of the the following findings should the nurse report to the provider?

Correct Answer is C

Explanation

A nurse is caring for a client who is at 36 weeks of gestation and is undergoing a nonstress test (NST). The test is nonreactive. Which of the following interventions should the nurse suggest based on the findings?

A nurse is reinforcing discharge teaching with a client who has stable angina pectoris. Which of the following statements by the client indicates an understanding of what to do when chest pain occurs?

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A nurse is reinforcing teaching about sexual activity during pregnancy for a client in a monogamous, same-sex relationship. Which of the following statements should the nurse make?

A nurse in an assisted-living facility is reinforcing teaching with staff members about preparing for an external chemical disaster. Which of the following instructions should the nurse include?

A nurse is assisting in the care of a client who presents to the emergency department. Exhibits A nurse is reviewing the client's medical record. Which of the following findings indicate the need for further evaluation? Select all that apply.

A nurse is reinforcing teaching with another nurse about how to change an ostomy appliance for a client who has a sigmoid colostomy. Which of the following instructions should the nurse include in the teaching?

A nurse is assisting with the care of an adolescent.

Exhibits

Complete the following sentence by using the lists of options.

The adolescent is at risk for developing
dropdown
evidenced by
dropdown