Patient Data
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.
Provide morphine 2 mg IV push (IVP).
Inspect the bandage for drainage.
Check capillary refill on bilateral upper extremities.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}
• Palpate and compare radial pulses: Assessing radial pulses bilaterally is essential after humeral fracture and surgical repair because neurovascular compromise is a major complication. Detecting differences in pulse quality can help identify impaired circulation or compartment syndrome early.
• Administer ondansetron 4 mg IV: The client reports nausea postoperatively, which can increase discomfort and risk for aspiration. Ondansetron is prescribed and effective in controlling nausea by blocking serotonin receptors in the gut and brain, making it an appropriate intervention.
• Perform range of motion: With a displaced humeral head/neck fracture and immediate postoperative status, range-of-motion exercises are contraindicated. Movement of the joint could disrupt fixation, increase bleeding, or worsen pain. Immobilization and stabilization are priorities.
• Provide morphine 2 mg IV push (IVP): The client has a prescription for morphine for severe pain, and his reported pain was previously 10/10 before surgery. Administering morphine is indicated to ensure adequate pain control, prevent sympathetic stress responses, and promote rest and healing.
• Inspect the bandage for drainage: Checking the surgical bandage is necessary to monitor for bleeding or excessive drainage, which may indicate complications such as hemorrhage or infection. Since the order specifies not to remove the dressing, visual inspection only is the correct approach.
• Check capillary refill on bilateral upper extremities: Capillary refill helps evaluate peripheral perfusion, which is critical after orthopedic surgery. Comparing both extremities provides baseline data and helps detect vascular compromise that could threaten limb viability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Monitor an IV infusion rate on an established schedule: This task is appropriate for a UAP because it involves observation and reporting rather than clinical decision-making. The UAP can ensure the IV is running at the prescribed rate and alert the nurse if any deviations occur.
B. Titrate oxygen to the prescribed parameters: Adjusting oxygen requires clinical judgment and assessment of respiratory status, including oxygen saturation and signs of hypoxia. This is a nursing responsibility and cannot be delegated to a UAP.
C. Insert a urinary catheter for an uncomplicated client: Catheter insertion is a sterile procedure that requires nursing knowledge and skill. Delegation to a UAP is not permitted due to the risk of infection and need for proper technique.
D. Procure platelet products from the blood bank: Obtaining blood products involves verification of patient identifiers, blood type, and compatibility, which are nursing responsibilities. This task requires clinical accountability and cannot be delegated to a UAP.
Correct Answer is B
Explanation
A. Report any increase in the white blood cell count: An elevated WBC may indicate infection, but this is a late finding and does not directly prevent recurrence. Reporting lab changes is important but not the most immediate or effective intervention
B. Change the surgical dressing when soiled: Keeping the surgical site clean and dry is the most critical step in preventing wound infection, particularly in clients with a history of MRSA. A soiled dressing promotes bacterial growth and increases the risk of reinfection, making timely dressing changes essential.
C. Wear a face mask while performing wound care: A face mask protects against droplet spread but MRSA is primarily transmitted by direct contact. While masks may reduce overall infection risk, they are less critical than maintaining strict wound and dressing hygiene.
D. Instruct the family to adhere to contact precautions: Family education is important in preventing MRSA transmission, but in the immediate postoperative period, the nurse’s priority is direct wound care. Preventing contamination at the surgical site takes precedence.
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