An adolescent client with non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. The healthcare provider collects bone aspirate specimens for culture and sensitivity and applies a cast to the adolescent's lower leg. Which action should the nurse implement next?
Begin parenteral antibiotic therapy.
Administer antiemetic agents.
Provide a high-calorie, high-protein diet.
Bivalve the cast for distal compromise.
The Correct Answer is A
A. Begin parenteral antibiotic therapy.
This is the correct answer. Osteomyelitis is a serious bone infection that requires prompt and aggressive antibiotic therapy to prevent further complications and promote healing.
B. Administer antiemetic agents.
Antiemetic agents may be necessary if the client is experiencing nausea or vomiting, but this is not the priority action.
C. Provide a high-calorie, high-protein diet.
While nutritional support is important for healing, initiating antibiotic therapy to address the infection takes precedence.
D. Bivalve the cast for distal compromise.
Bivalving the cast might be necessary if there is evidence of compartment syndrome or impaired circulation, but there is no indication from the question that such a complication is present at this time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Compare muscle strength bilaterally. While hyperkalemia can lead to muscle weakness, assessing muscle strength bilaterally is not the most critical intervention in this scenario. The priority is to assess for cardiac manifestations of hyperkalemia.
B. Determine apical pulse rate and rhythm. Hyperkalemia can cause life-threatening cardiac dysrhythmias, including bradycardia, heart block, and ventricular tachycardia. Assessing the apical pulse rate and rhythm can provide essential information about cardiac function and help identify potential dysrhythmias.
C. Assess strength of deep tendon reflexes. Hyperkalemia can affect neuromuscular function, leading to hyperreflexia or diminished reflexes. While assessing deep tendon reflexes is
important, it is not as critical as assessing cardiac function in a client with known hyperkalemia.
D. Observe color and amount of urine. While changes in urinary output and characteristics may indicate renal impairment associated with hyperkalemia, the priority in this situation is to assess for cardiac manifestations of hyperkalemia.
Correct Answer is C
Explanation
A. Encouraging the client to participate in a team sport may be overwhelming and unrealistic given the client's current level of depression and lack of activity. Starting with smaller, more achievable goals is essential in the initial stages of treatment.
B. Helping the client develop a list of daily affirmations is a positive intervention for promoting self-esteem, but it may not address the immediate need for increasing activity levels or engagement in meaningful activities.
C. Assisting the client in identifying goals for the day is the most important intervention at this stage. Setting achievable daily goals can help the client regain a sense of purpose and motivation. These goals should be realistic and tailored to the client's current abilities and interests.
D. Scheduling the client for a group focusing on self-esteem is beneficial, but it may not directly address the client's need for increased activity and engagement in meaningful daily activities.
Goals related to self-esteem can be incorporated into the client's plan of care but should be part of a comprehensive approach to treatment.
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