An elderly patient who had a fall at a store is admitted with a potential right hip fracture.
What assessment finding should the nurse report to the healthcare provider?

The left lower extremity is warm to touch.

Bilateral pedal pulses are present and strong.

The patient wiggles their right toes when the sole of the right foot is tickled.

The right leg is externally rotated and shorter than the left.

Answer and Explanation

The Correct Answer is D

Choice A rationale

While it’s important to assess all aspects of the patient’s condition, a warm left lower extremity does not necessarily indicate a right hip fracture. It could be related to other conditions, such as deep vein thrombosis or cellulitis.

Choice B rationale

The presence of strong bilateral pedal pulses is a positive sign and does not indicate a hip fracture. It suggests that the patient has good peripheral circulation.

Choice C rationale

The ability to wiggle the toes when the sole of the right foot is tickled does not necessarily indicate a hip fracture. This is a normal response and suggests that the patient has intact sensory and motor function in the foot.

Choice D rationale

A right leg that is externally rotated and shorter than the left is a classic sign of a hip fracture. This occurs because the fracture can cause the femoral head to tilt and rotate outward, making the leg appear shorter.

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Correct Answer is B

Explanation

Choice A rationale

While nausea and vomiting can be side effects of eye surgery, they are not typically associated with acute pain deep within the eye following laser trabeculoplasty. Therefore, administering an antiemetic would not address the client’s primary complaint.

Choice B rationale

Acute pain deep within the eye following laser trabeculoplasty is not a typical postoperative symptom and could indicate a complication such as increased intraocular pressure or inflammation. Therefore, the nurse should report this complaint to the surgeon immediately for further evaluation.

Choice C rationale

While eye shields can help reduce photosensitivity after eye surgery, they would not typically alleviate acute pain deep within the eye. Therefore, this action would not address the client’s primary complaint.

Choice D rationale

While prophylactic antibiotics can help prevent infection after eye surgery, they would not typically alleviate acute pain deep within the eye. Therefore, this action would not address the client’s primary complaint.

A. Prompt the nurse to apply povidone to the site. B. Direct the nurse to attach the luer-lock tip to the irrigation port. C. Send an unlicensed assistive personnel to gather equipment. D. Instruct the nurse to use water with 5% dextrose (D5W).

Correct Answer is B

Explanation

Choice A rationale

Prompting the nurse to apply povidone to the site is not the correct action in this scenario. Povidone-iodine is an antiseptic used for skin disinfection before and after surgery. It is not typically used in the process of irrigating an intravenous catheter.

Choice B rationale

Directing the nurse to attach the luer-lock tip to the irrigation port is the correct action. A luer-lock syringe is commonly used in medical procedures, including the irrigation of an intravenous catheter. The luer-lock tip provides a secure connection to prevent leaks and ensure that the irrigation solution is delivered directly to the catheter.

Choice C rationale

Sending an unlicensed assistive personnel to gather equipment is not the most appropriate action in this scenario. The new nurse has already gathered the necessary equipment for the procedure.

Choice D rationale

Instructing the nurse to use water with 5% dextrose (D5W) is not the correct action. D5W is a type of intravenous fluid used to correct dehydration and provide calories to the patient. It is not typically used for irrigating an intravenous catheter.

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An elderly patient who had a fall at a store is admitted with a potential right hip fracture.What assessment finding should the nurse report to the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye.Which action should the nurse take?

Correct Answer is B

Explanation

The charge nurse observes a new nurse preparing to irrigate an intravenous catheter.The new nurse has a luer-lock tipped syringe.What action should the charge nurse take?

Correct Answer is B

Explanation

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An elderly patient who had a fall at a store is admitted with a potential right hip fracture.
What assessment finding should the nurse report to the healthcare provider?