A nurse is caring for a client who has a fractured right femur.
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While maintaining eye contact during feedings can foster bonding and comfort, it is not specifically beneficial for managing symptoms of neonatal abstinence syndrome (NAS).
B. Minimizing noise in the newborn's environment is crucial for a baby with NAS. These infants often have increased sensitivity to stimulation and can become easily agitated. A quiet, calming environment can help soothe them.
C. Administering naloxone to a newborn with NAS is not recommended. Naloxone is an opioid antagonist and, while it can reverse opioid effects acutely, it is not a treatment for the withdrawal symptoms associated with NAS.
D. Swaddling the newborn is beneficial, but the legs should not be extended.
Swaddling should allow for some movement of the legs and hips to prevent the development of hip dysplasia. Swaddling in a way that allows the legs to bend and move is generally recommended.
Correct Answer is A
Explanation
A. Encouraging the use of assistive devices like canes can help improve stability and prevent falls in individuals with multiple sclerosis who may experience balance issues. This statement promotes safety and independence in mobility.
B. While exercise is beneficial for individuals with multiple sclerosis, recommending a rigorous program may not be appropriate initially and could potentially exacerbate symptoms.
C. Hot baths can exacerbate symptoms in individuals with multiple sclerosis due to heat sensitivity, so this advice may not be suitable.
D. Scatter rugs can pose a tripping hazard, especially for individuals with mobility issues, so this statement is incorrect and may increase the risk of falls.
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