Exhibits
Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.
Check capillary refill on bilateral upper extremities.
Administer ondansetron 4 mg IV.
Inspect the bandage for drainage.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"}}
Based on the provided information, here are the interventions the nurse should perform:
- Check capillary refill on bilateral upper extremities. - Indicated: This is important to assess the client’s circulation, especially given the coolness of the left arm and the fracture in the left shoulder.
- Administer ondansetron 4 mg IV. - Contraindicated: There is no prescription for ondansetron and no indication of nausea or vomiting from the client.
- Inspect the bandage for drainage. - Indicated: Given the client’s recent surgery and the presence of swelling and bruising, it’s important to monitor for any signs of infection or complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A. The nurse should first implement the prescription of Cefazolin 1 gram intravenously every 6 hours.
This is because, on admission of a patient to the postanesthesia care unit (PACU) from surgery, the first priority is to assess the airway and breathing status. Administering Cefazolin, an antibiotic, helps prevent postoperative infections, which is crucial in the immediate postoperative period.
Correct Answer is C
Explanation
Choice A rationale
While understanding risk factors for osteoporosis is important, it is not the highest priority for an older adult client diagnosed with osteoporosis. The highest priority is ensuring the client’s safety to prevent falls and fractures.
Choice B rationale
While constipation due to immobility can be a concern for clients with osteoporosis, it is not the highest priority for an older adult client diagnosed with osteoporosis. The highest priority is ensuring the client’s safety to prevent falls and fractures.
Choice C rationale
Identifying home safety hazards to be resolved immediately is the highest priority for an older adult client diagnosed with osteoporosis. Osteoporosis increases the risk of fractures, and falls are a common cause of fractures in older adults. Therefore, ensuring a safe environment is crucial.
Choice D rationale
While adding calcium-rich foods to the daily diet can help manage osteoporosis, it is not the highest priority for an older adult client diagnosed with osteoporosis. The highest priority is ensuring the client’s safety to prevent falls and fractures.
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