A nurse is caring for a client in an orthopedic unit.

Exhibits

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

The client is at risk for developing
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and
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Answer and Explanation

The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}

Deep vein syndrome: This is not a recognized condition. The intended term may have been deep vein thrombosis (DVT), which is a valid orthopedic complication, but the clinical findings in this scenario point more urgently toward compartment syndrome and infection.
Osteomyelitis: The client has an open fracture with drainage from the splint, a significantly elevated WBC count (28,000/mm³), and a high fever (38.9°C / 102°F). These findings suggest the development of a bone infection (osteomyelitis), especially in the context of recent surgery and internal fixation.
Fat embolism syndrome: While fat embolism is a risk with long bone fractures, this client is not displaying key hallmark signs such as respiratory distress, petechiae, or altered mental status. The findings are more consistent with infection and circulatory compromise.
Compartment syndrome: The client has classic signs including cool foot, numbness, inability to move toes, absent pulses, delayed capillary refill, and increased pain. These are hallmark signs of neurovascular compromise from compartment syndrome, a surgical emergency.

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Correct Answer is ["D","E"]

Explanation

A. Ensure the formula is cold before administration. Enteral formula should be given at room temperature to avoid causing gastrointestinal cramping or discomfort. Cold formula can irritate the GI tract and lead to intolerance.
B. Check placement of the feeding tube by x-ray once daily. An x-ray is used initially to confirm tube placement after insertion, but daily x-rays are not required. Ongoing checks are done through aspirate checks and measuring external tube length.
C. Maintain the head of the client's bed at a 20° angle or higher. The head of the bed should be elevated to at least 30 to 45 degrees to prevent aspiration. A 20° angle is insufficient and increases the risk of aspiration pneumonia.
D. Check gastric residuals every 4 hr. This is appropriate for clients receiving continuous feedings. Monitoring gastric residual volume (GRV) every 4 hours helps assess tolerance to the feeding and reduces the risk of aspiration.
E. Change the feeding container and tubing every 24 hr. To prevent bacterial contamination, the feeding bag and tubing should be changed every 24 hours when using an open system. This is a standard infection control practice.

A. "The estimated blood loss was 250 milliliters." B. "The client was intubated without complications." C. "There was a total of 10 sponges used during the procedure." D. The client is a member of the board of directors."

Correct Answer is A

Explanation

A. "The estimated blood loss was 250 milliliters." This is a relevant clinical detail that directly impacts the client’s postoperative care. It provides important information for ongoing assessment of fluid status, potential for anemia, and need for interventions.
B. "The client was intubated without complications." While important during surgery, this is less relevant in the postoperative period unless the intubation caused complications or the client remains intubated. It does not guide current nursing care.
C. "There was a total of 10 sponges used during the procedure." Sponge counts are part of surgical safety and accountability, but they are not typically necessary in nursing hand-off unless a retained item is suspected.
D. "The client is a member of the board of directors." This is not clinically relevant and could breach confidentiality or bias care. Hand-off reports should focus solely on the client’s medical condition and nursing care needs.

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A nurse is caring for a client in an orthopedic unit. Exhibits Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing dropdownanddropdown

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following actions should the nurse take? (Select all that apply)

Correct Answer is ["D","E"]

Explanation

A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?

Correct Answer is A

Explanation

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The nurse continues to care for the client. Exhibits A nurse on the inpatient mental health unit is planning care for the client. For each potential provider's prescription, click to specify if the prescription is anticipated or contraindicated for the client.

A nurse reviews the provider prescriptions and reassesses the client. Exhibits The nurse is continuing to care for the client. Which of the following actions should the nurse take? Select all that apply.

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A nurse is caring for a client in an orthopedic unit.

Exhibits

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

The client is at risk for developing
dropdown
and
dropdown