Exhibits
The nurse reviews the prescriptions 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.
Palpate and compare radial pulses.
Administer ondansetron 4 mg IV.
Perform range of motion.
Check capillary refill on bilateral upper extremities.
Inspect the bandage for drainage.
Provide morphine 2 mg IV push (IVP).
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}
Rationale:
- Palpate and compare radial pulses: It is important to check radial pulses to assess circulation to the injured limb. Decreased pulse strength, especially in the left arm, could indicate vascular injury, which requires immediate attention.
- Administer ondansetron 4 mg IV: The client is feeling nauseated and worries about vomiting, likely due to postoperative effects, pain medication, or anesthesia. Ondansetron is an antiemetic, which is appropriate to administer to manage nausea and prevent vomiting.
- Check capillary refill on bilateral upper extremities: Checking capillary refill is essential to assess perfusion to both arms. The client’s left arm is experiencing coolness, and diminished pulses were noted earlier, so this is necessary to monitor blood flow and prevent complications like compartment syndrome.
- Inspect the bandage for drainage: After surgery, it is important to inspect the surgical site for any drainage, bleeding, or signs of infection. This helps ensure that there are no complications or issues with wound healing.
- Perform range of motion: Performing range of motion exercises is contraindicated immediately after trauma, especially with a fracture or suspected injury to the shoulder. The shoulder should be immobilized to prevent further damage and to facilitate proper healing. Early movement may worsen the injury or cause additional pain.
- Provide morphine 2 mg IV push (IVP): While he had a nerve block, its effectiveness will wane, and he will likely experience significant pain from the fracture and surgical manipulation. Administering prescribed analgesia like morphine is a priority for pain management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Ask if the client is experiencing any change in bowel habits: Changes in bowel habits are not directly related to the confusion or memory loss seen in pernicious anemia. The concern here is primarily with vitamin B12 deficiency.
B. Determine if the client is taking iron and folic acid supplements: While iron and folic acid are important, they don't directly address the memory loss and confusion related to B12 deficiency. The immediate focus should be on the effects of the B12 treatment.
C. Encourage the husband to bring the client to the clinic for a complete blood count: A CBC can help monitor anemia, but it doesn't address the memory issues. The nurse should first explain the symptoms related to B12 deficiency.
D. Explain that memory loss and confusion are common with vitamin B12 deficiency:
Memory loss and confusion are known symptoms of vitamin B12 deficiency. These symptoms may take time to improve with treatment, and educating the husband helps alleviate concerns.
Correct Answer is ["0.6"]
Explanation
Rationale:
- Convert the client's weight from pounds (lb) to kilograms (kg).
Weight in kg = 154 lb / 2.2 lb/kg
= 70 kg.
- Calculate the total desired dose in units.
Desired dose (units) = Desired dose (units/kg) × Weight (kg)
= 200 units/kg × 70 kg
= 14000 units.
Available concentration of the medication = 25,000 units/mL.
- Calculate the volume in milliliters (mL) to administer.
Volume (mL) = Desired dose (units) / Available concentration (units/mL)
= 14000 units / 25000 units/mL
= 0.56 mL.
- Round the answer to the nearest tenth.
= 0.6.
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