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 D

Explanation

A. Adding medication directly to enteral feeding can cause clogging of the tube and interfere with medication absorption.
B. Flushing with only 5 mL of water is insufficient. Typically, the tube should be flushed with 15-30 mL of water before and after administering each medication to ensure the tube is clear and to prevent clogging.
C. Dissolving medications together may lead to drug interactions or alterations in drug absorption and should be avoided.
D. Using a syringe to allow the medications to flow by gravity ensures that the medications are delivered safely and steadily. After each medication is administered, the tube should be flushed with water to ensure it is clear and to prevent interactions between different medications.

A. Administer sedation for the procedure. B. Schedule an MRI postprocedure to verify placement. C. Use gauze to secure an arm board to the involved extremity. D. Measure the arm circumference above the insertion site daily

Correct Answer is D

Explanation

A: Sedation is not typically required for PICC line insertion; local anesthesia is usually sufficient.
B: An MRI is not the standard method to verify PICC line placement; an x-ray is typically used.
C: Using gauze to secure an arm board can restrict circulation and is not recommended for securing a PICC line.
D: Measuring the arm circumference daily is important to monitor for complications such as swelling or phlebitis at the insertion site.

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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 preparing to administer three medications to a client who is receiving continuous enteral feeding through an NG tube. Which of the following actions is appropriate for the nurse to take?

Correct Answer is D

Explanation

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Correct Answer is D

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.