A nurse is caring for a client who has a fractured right femur.

Exhibits

Select the 4 findings on day 2 that require immediate follow-up.

Pedal pulses

Breath sounds

Heart rate

Movement of right foot

Respiratory rate

Pulse oximetry

Answer and Explanation

Correct Answer : B,C,E,F

A.   While it's important to assess pedal pulses regularly, there is no indication in the scenario that the pedal pulses are abnormal or require immediate follow-up. The description mentions bilateral pedal pulses being present and intact throughout both days, suggesting no acute issues with peripheral circulation.

B.   Crackles heard at the bases indicate possible pulmonary complications such as atelectasis or pneumonia, requiring further assessment and intervention.
C.   A heart rate of 112/min indicates tachycardia, which could be a sign of pain, anxiety, or underlying cardiovascular issues. Further evaluation is needed to determine the cause.
D.   The scenario states that the movement and sensation of the right foot are intact, with warm skin and no change in pigmentation. There are no signs of compromised neurovascular status in the right foot based on the provided information, so immediate follow-up for this finding is not necessary.
E.   A respiratory rate of 28/min is elevated, suggesting respiratory distress or inadequate ventilation. Prompt assessment and intervention are necessary to address any respiratory issues.
F.   A pulse oximetry reading of 88% on room air indicates hypoxemia, which requires immediate attention to ensure adequate oxygenation. Further assessment and intervention are needed to improve oxygen saturation levels.

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Correct Answer is ["A","B","C"]

Explanation

The presence of more frequent headaches and difficulty sleeping, coupled with a significant increase in blood pressure (BP 169/91 mm Hg), could suggest potential adverse effects of the medication phenelzine, which is known to cause headaches and hypertensive reactions. It is crucial for the nurse to monitor these symptoms closely, as they may require medical attention and could indicate the need for an adjustment in the client's treatment plan. The client's vital signs should be regularly monitored, and any new or worsening symptoms should be reported to the healthcare provider promptly to ensure the client's safety and well-being.

A. Determine the need for additional providers. B. Act as a spokesperson to provide information to the media. C. Recommend to the provider a list of clients for early discharge. D. Decide which clients should be transported for a higher level of care.

Correct Answer is C

Explanation

A. Determine the need for additional providers: Determining the need for additional providers is typically the responsibility of the hospital administration or incident command team, not the unit nurse.

B. Act as a spokesperson to provide information to the media: Communication with the media is managed by designated public relations personnel or a hospital spokesperson, not the unit nurse.

C. Recommend to the provider a list of clients for early discharge: The unit nurse is responsible for assessing which clients are stable enough for discharge and communicating these recommendations to the provider. This helps prioritize bed availability and ensures appropriate allocation of resources during a disaster.

D. Decide which clients should be transported for a higher level of care: This decision is typically made by the disaster management team or the provider, with input from the nurse. Nurses may report clinical details to help inform the decision but do not make the final determination.

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A nurse is caring for a client who has a fractured right femur. Exhibits Select the 4 findings on day 2 that require immediate follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C"]

Explanation

A nurse manager on an interprofessional team is creating a disaster plan. The nurse should include in the plan that which of the following actions is the responsibility of the unit nurse during a disaster?

Correct Answer is C

Explanation

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A nurse is caring for a client who has a fractured right femur.

Exhibits

Select the 4 findings on day 2 that require immediate follow-up.