An adolescent patient with a non-union of a comminuted fracture of the tibia is admitted with osteomyelitis.
After the healthcare provider collects bone aspirate specimens for culture and sensitivity and applies a cast to the adolescent’s lower leg, what should the nurse do next?

Provide a high-calorie, high-protein diet

Begin parenteral antibiotic therapy

Administer antiemetic agents

Bivalve the cast for distal compromise .

Answer and Explanation

The Correct Answer is B

Choice A rationale
While a high-calorie, high-protein diet can be beneficial for patients recovering from surgery or illness, it is not the immediate next step after collecting bone aspirate specimens for culture and sensitivity and applying a cast to a patient’s lower leg. The priority is to address the infection identified through the bone aspirate specimens.

Choice B rationale
Beginning parenteral antibiotic therapy is the appropriate next step after collecting bone aspirate specimens for culture and sensitivity in a patient with osteomyelitis. Osteomyelitis is an infection in the bone, and antibiotics are typically the first line of treatment. Therefore, this choice is the correct answer.
Choice C rationale
Administering antiemetic agents would be appropriate if the patient were experiencing nausea or vomiting. However, there is no indication in the question that the patient is experiencing these symptoms. Therefore, this choice is not the correct answer.
Choice D rationale
Bivalving the cast for distal compromise would be appropriate if there were signs of compromised circulation or nerve function below the level of the cast. However, there is no indication in the question that the patient is experiencing these issues. Therefore, this choice is not the correct answer.

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Correct Answer is A

Explanation

Choice A rationale
Given the client’s risk factors of poor wound healing, decreased bone density, and increased capillary fragility, the most appropriate outcome statement to include in the plan of care is that the client implements measures to prevent injury. This includes avoiding falls, using caution with sharp objects to prevent cuts, and taking steps to protect the bones.
Choice B rationale
While it is important for the client to understand their disease and ways to control it, this is not the most appropriate outcome statement given the client’s specific risk factors.
Choice C rationale
Improving body image may be a relevant goal for some clients with Cushing’s syndrome, but it is not the most appropriate outcome statement given the client’s specific risk factors.
Choice D rationale
Experiencing a normal fluid balance may be a relevant goal for some clients with Cushing’s syndrome, but it is not the most appropriate outcome statement given the client’s specific risk factors.

A. Estimate the blood pressure by assessing the pulse volume of the client's radial pulses. B. Document why the blood pressure cannot be accurately measured at the present time. C. Advise the UAP to document the last blood pressure obtained on the client's graphic sheet. D. Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed.

Correct Answer is D

Explanation

A. Estimating blood pressure based on the strength or quality of the radial pulse is not a reliable method. Pulse volume can provide only a very rough sense of perfusion but does not give a numeric measurement of systolic or diastolic pressure. Relying on this method could lead to inaccurate assessment, delayed recognition of hypotension or hypertension, and inappropriate clinical interventions, putting the client at risk.

B. While it is essential to document the limitations in obtaining vital signs, documentation alone does not resolve the issue. The client still needs accurate and timely blood pressure measurements for safe monitoring and care, especially if they have a condition that could compromise hemodynamic stability. Simply recording that measurement is not possible fails to meet the standard of care.

C. Using a previous blood pressure reading is unsafe because it does not reflect the client’s current condition. Vital signs can change rapidly due to fluid shifts, pain, medications, or other medical issues. Documenting an old reading can mislead the care team and result in inappropriate interventions or delayed response to changes in the client’s status.

D. This is the most appropriate and safe action. When the upper extremities are unavailable due to casts or injury, alternative validated sites, such as the popliteal artery, should be used. The nurse can teach the UAP how to position the client correctly, flexing the knee while supine, to allow proper cuff placement and accurate measurement. This ensures the client receives safe and reliable monitoring, and the staff is competent in using alternative techniques when standard sites are inaccessible.

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An adolescent patient with a non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. After the healthcare provider collects bone aspirate specimens for culture and sensitivity and applies a cast to the adolescent’s lower leg, what should the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is developing the plan of care for a client diagnosed with Cushing’s syndrome and identifies that the client’s risk factors include poor wound healing, decreased bone density, and increased capillary fragility. Which outcome statement should the nurse include in the plan of care?

Correct Answer is A

Explanation

The unlicensed assistive personnel (UAP) reports that a client’s blood pressure cannot be measured in the arms because the client has casts on both arms and is unable to be measured in the legs because the client is in the supine position. Which action should the nurse implement?

Correct Answer is D

Explanation

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An adolescent patient with a non-union of a comminuted fracture of the tibia is admitted with osteomyelitis.
After the healthcare provider collects bone aspirate specimens for culture and sensitivity and applies a cast to the adolescent’s lower leg, what should the nurse do next?