A patient has had surgical reduction of an open fracture of the right radius this morning. Which assessment findings should the nurse report immediately to the health care provider?
Right arm muscle spasms
Temperature of 99.9°F (37.7°C)
Loss of the right radial pulse
Pain with right arm movement
The Correct Answer is C
Choice A reason: Right arm muscle spasms may be uncomfortable but are not as critical as circulatory issues.
Choice B reason: A temperature of 99.9°F (37.7°C) is slightly elevated but not immediately alarming post-surgery.
Choice C reason: Loss of the right radial pulse could indicate a serious complication such as compartment syndrome, which requires urgent atention.
Choice D reason: Pain with arm movement is expected post-surgery but is not as urgent as loss of pulse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Instructing the client to cut back to one or two drinks per day may not be effective for someone with cirrhosis, as any amount of alcohol can be harmful.
Choice B reason: Educating the client about the disease and the specific risks associated with alcohol consumption can provide the motivation needed to make a change.
Choice C reason: Introducing the client to other people who do not drink alcohol could provide social support, but it is not the primary step in motivating change.
Choice D reason: Telling the client that their liver has been destroyed by alcohol might be factual, but it is not a constructive approach to motivate change.
Correct Answer is A
Explanation
Choice A reason: Stopping the transfusion immediately is the first and most critical action in response to signs of a possible transfusion reaction, which can be life-threatening.
Choice B reason: While informing the provider is a necessary step, it should come after stopping the transfusion to prevent further harm to the patient.
Choice C reason: Calling the lab is an appropriate action but not the first priority. The immediate concern is the patient's safety.
Choice D reason: Obtaining a urine specimen may be part of the diagnostic process for a transfusion reaction, but it is not the first action to take.
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