A nurse is caring for a client following an open reduction and internal fixation of a fractured femur.
Which of the following findings is the nurse's priority?
Headache.
Altered level of consciousness.
Muscle spasms.
Oral temperature of 37.7C (99.86F).
The Correct Answer is B
Choice A rationale
Headache could indicate various conditions but is not immediately life-threatening post-surgery. It may be due to medication or anesthesia but is not the priority.
Choice B rationale
Altered level of consciousness (LOC) is a critical finding. It may indicate complications such as hemorrhage, fat embolism, or hypoxia, which require urgent assessment and intervention.
Choice C rationale
Muscle spasms can be a common symptom post-surgery due to pain or positioning. While they need management, they do not take precedence over LOC changes.
Choice D rationale
An oral temperature of 37.7°C is slightly elevated but not alarming. It may be due to the body's normal inflammatory response post-surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Administering syrup of ipecac to induce vomiting is no longer recommended due to the risk of aspiration and potential harm from the substance ingested.
Choice B rationale
Giving orange juice won't counteract iron poisoning from ferrous sulfate and may actually increase iron absorption, exacerbating the situation.
Choice C rationale
Contacting the poison control center is the most appropriate action as they provide expert guidance on managing iron overdose and other poisoning scenarios.
Choice D rationale
Providing a high-carbohydrate snack is not relevant or effective in treating iron poisoning and can delay appropriate medical intervention.
Correct Answer is ["2"]
Explanation
Step 1 is to determine the number of tablets needed. (500 mg ÷ 250 mg/tablet) = 2 tablets.
The nurse should administer 2 tablets.
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