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 B
Explanation
Choice A rationale
While advising family members to monitor for symptoms of illness is important, it’s not the most crucial action for the nurse to take immediately after testing the patient for COVID-194.
Choice B rationale
Implementing droplet precautions, placing the patient in a private room, and keeping the door closed is the most crucial action. This helps prevent the potential spread of COVID-19 to other patients and healthcare workers.
Choice C rationale
Informing the patient to notify others about potential exposure is important, but it’s not the most crucial action immediately after testing.
Choice D rationale
Initiating an IV infusion for the administration of an antiviral drug is not the most crucial action. Antiviral medication is typically administered after a positive test result, not before.
Correct Answer is ["A","B","C","D"]
Explanation
D.
Choice A rationale
Administering morphine as prescribed would help to manage the patient’s reported pain.
Choice B rationale
Monitoring the patient’s vital signs is crucial in assessing the patient’s physiological response to the fall and ensuring stability.
Choice C rationale
Applying a cold pack to the affected area can help to reduce swelling and alleviate pain.
Choice D rationale
Arranging for an X-ray of the left shoulder would help to identify any potential fractures or other injuries resulting from the fall.
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