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 B

Explanation

A. Making the child NPO is not necessary for an EEG procedure.

B. Ensuring the child's hair is clean and without conditioner helps to optimize the quality of the EEG recording by reducing interference from oils and residues on the scalp.
C. There is no need to restrict the child from sun exposure following an EEG procedure.
D. Acetaminophen is not typically indicated for pain relief following an EEG procedure, as it is non-invasive and generally well-tolerated.

A. "You can douche twice weekly." B. "Wear loose-fitting clothing." C. "Wear flat or low-heeled shoes." D. "Take hot showers to help relieve itching." E. "You should avoid fried foods." F. "Try using an abdominal support belt." G. "Eat two large meals a day."

Correct Answer is ["B","C","E","F"]

Explanation

A. Douching is not recommended during pregnancy as it can disrupt the natural balance of vaginal flora and increase the risk of infection.
B. Loose-fitting clothing allows for better air circulation and can help prevent discomfort and irritation, especially with increased sweating and vaginal discharge during pregnancy.

C. Flat or low-heeled shoes provide better support and stability, reducing the strain on the back and pelvis, which can alleviate backaches common during pregnancy.
D. Hot showers can exacerbate itching, especially if the skin is already irritated.

Lukewarm or cool showers are preferable for relieving itching.

E. Fried foods can contribute to heartburn and indigestion, which are common during pregnancy due to hormonal changes and increased pressure on the stomach from the growing uterus.
F. An abdominal support belt can help alleviate backaches by providing additional support to the abdomen and reducing strain on the back muscles.
G. Eating frequent, smaller meals throughout the day is recommended during pregnancy to help manage heartburn, prevent overeating, and maintain stable blood sugar levels.

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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

A nurse is teaching the parents of a child who has a new onset of seizures and is to undergo an electroencephalogram (EEG) about the procedure. Which of the following instructions should the nurse include in teaching?

Correct Answer is B

Explanation

A nurse in an outpatient clinic is caring for a client. Exhibits Which of the following statements should the nurse include in the client's teaching? Select all that apply.

Correct Answer is ["B","C","E","F"]

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.