An older adult client fell while getting out of bed. Which assessment finding indicates a possible hip fracture?

The client cries out when the nurse attempts to examine him.

The client is extremely confused and trying to get up.

The skin of one leg is cooler than that of the upper extremities,

One leg is shorter than the other and has a protruding bump on the side.

Answer and Explanation

The Correct Answer is D

This finding suggests that the client may have experienced a hip fracture. The shorter leg can be a result of the fractured bone, causing a misalignment or displacement. The protruding bump on the side can be a sign of a dislocated or fractured hip joint. It is important to assess and confirm this suspicion through appropriate diagnostic measures, such as X-rays, to provide the necessary medical intervention and management.

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Correct Answer is A

Explanation

A 3% saline solution is a hypertonic solution used to increase serum sodium levels in cases of severe hyponatremia. However, it can lead to fluid overload and pulmonary edema. The presence of crackles throughout both lung fields indicates the accumulation of fluid in the lungs, which is a serious adverse outcome.

The patient's radial pulse rate of 105 beats/min is within a normal range and does not directly indicate an adverse effect of the saline infusion.

The presence of sediment and blood in the patient's urine may be unrelated to the 3% saline infusion and could indicate other issues such as urinary tract infection or kidney injury.

An increase in blood pressure from 66/50 to 122/74 mmHg is an expected effect of a hypertonic solution like 3% saline, as it can cause an increase in intravascular volume. While the increase in blood pressure is significant, it does not represent an adverse outcome specific to the infusion itself.

A. A patient who follows a strict vegetarian diet. B. A patient who is morbidly obese C. A patient who is 6 weeks pregnant. D. A patient who drinks a glass of wine monthly.

Correct Answer is B

Explanation

Excess body weight, particularly in the abdominal area, can increase intra-abdominal pressure and lead to the weakening of the lower esophageal sphincter (LES). The LES is responsible for preventing stomach acid from flowing back into the esophagus. When it becomes weakened, it can contribute to the development of GERD. Other risk factors for GERD include certain dietary choices, such as consuming fatty and spicy foods, smoking, pregnancy, and alcohol consumption.

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An older adult client fell while getting out of bed. Which assessment finding indicates a possible hip fracture?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data represents an adverse outcome (side effect) of this infusion?

Correct Answer is A

Explanation

The nurse is providing care to several patients in an outpatient clinic. Which patient is at highest risk of developing gastroesophageal reflux disorder (GERD)?

Correct Answer is B

Explanation

What are the most important nursing interventions for clients with possible renal calculi? List two.

After a change-of-shift report, which client should the nurse assess first?

A client's Sodium level is 128 meq/L. The nurse knows that a likely cause of this lab finding is:

The client is to receive an antibiotic 1 gram in 500 ml of fluid intravenously over 2 hours. At what rate will the nurse set the IV pump in mL/hr.? (Answer as whole number)

A 5-year-old with an arm cast from a fractured wrist complains of itching under his cast. The nurse knows cast care teaching for the parent has been successful when the parent states:

In replying to a client's questions about the seriousness of the chronic kidney disease (CKD), the nurse knows that the stage of CKD is based on what?

The nurse is caring for an adolescent diagnosed with scoliosis who just arrived to the floor from the recovery room after a Spinal fusion surgery. The nurse should question which physician order?