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 D
Explanation
Choice A reason: While having at least one stool per day is a sign that lactulose is working, it does not directly indicate its effectiveness in reducing ammonia levels and improving mental status.
Choice B reason: Denial of nausea and vomiting is positive but is not a direct indicator of lactulose's effectiveness in treating hepatic encephalopathy.
Choice C reason: A decrease in bilirubin levels may be a positive sign, but it is not a direct indicator of lactulose's effectiveness in treating hepatic encephalopathy.
Choice D reason: The client being alert and oriented is a direct indicator that lactulose is effectively reducing ammonia levels and improving mental status, which is a key goal in treating hepatic encephalopathy associated with liver cirrhosis.
Correct Answer is A
Explanation
Choice A reason: A healthy stoma should be beefy red and moist, indicating good blood supply and hydration.
Choice B reason: A dusky maroon color could indicate compromised blood supply or ischemia.
Choice C reason: A pale and pink stoma may suggest anemia or reduced blood flow.
Choice D reason: A stoma that is pink and dry could be dehydrated, which is not ideal.
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