Exhibits
The nurse reviews the orders and plans initial steps for caring for the client.
Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.
Inspect the bandage for drainage
Perform range of motion.
Administer ondansetron 4 mg IV.
Provide morphine 2 mg IV.
Check capillary refill on bilateral upper extremities
Palpate and compare radial pulses.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}
Inspect the bandage for drainage: This is a standard post-injury assessment to monitor for excessive bleeding or other complications.
Perform range of motion: Range of motion exercises are contraindicated in cases of fractures, as movement could worsen the injury.
Administer ondansetron 4 mg IV: Ondansetron is an antiemetic that can help relieve the nausea the client is experiencing.
Provide morphine 2 mg IV: Morphine is indicated for pain management, especially since the client is experiencing significant pain.
Check capillary refill on bilateral upper extremities: This is important to assess circulation and ensure there is no vascular compromise.
Palpate and compare radial pulses: This assesses circulation and can help identify any vascular injury or compromise due to the humeral fracture.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Providing one-on-one observation at all times is critical for ensuring the client's safety and monitoring for any further escalation of behavior or side effects from the administered medication. Continuous observation is essential in managing a client in seclusion.
B. While it is important to release the client when composure is regained, the immediate priority is ensuring safety through constant observation during the acute phase following seclusion.
C. Securing the room is important for safety, but the immediate focus should be on observing the client's behavior and mental status closely to prevent harm.
D. Observing for extrapyramidal symptoms is important, but the priority after seclusion is to ensure that the client remains safe and stable through one-on-one observation.
Correct Answer is A
Explanation
A. Nitroglycerin should be withheld because it can cause severe hypotension when administered to a client who has recently taken sildenafil, which also causes vasodilation.
B. Aspirin is generally safe to administer and can help with chest pain, especially if a myocardial infarction is suspected.
C. Heparin is an anticoagulant used for treating various conditions and is not contraindicated in this scenario.
D. Morphine can be administered to manage severe chest pain, as it is not contraindicated in this situation.
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