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. An abnormal level of consciousness is critical and can indicate decreased cerebral perfusion due to hypotension and rapid heart rate. This finding warrants immediate attention.
B. While a headache with sudden onset is concerning, it is less immediately critical than changes in consciousness.
C. Nausea with vomiting can occur with various conditions but is not as indicative of immediate deterioration as changes in mental status.
D. Flat JVD at 45 degrees does not provide as urgent information about the client’s status compared to changes in consciousness.
Correct Answer is A
Explanation
A. Applying oxygen via nasal cannula and ensuring oxygen saturation is above 93% is the priority action to alleviate hypoxia and reduce the workload on the heart, especially with the client’s symptoms of angina and shortness of breath.
B. While creating a calm environment is beneficial, it does not address the immediate concerns of oxygenation and potential cardiac issues.
C. Counting and recording premature ventricular contractions is important, but it is not the immediate priority compared to oxygenation.
D. Verifying troponin level assessments is necessary for cardiac monitoring, but immediate oxygen support takes precedence over lab tests.
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