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 C
Explanation
A. Ensure that the restraints are snug against the client's wrists: Restraints should be snug enough to prevent injury but not so tight as to impair circulation. However, this does not address the safety concern related to the type of knot used.
B. Move the ties so the restraints are secured to the side rails: Restraints should never be tied to the side rails because this can cause injury if the rail moves or the client attempts to climb over it.
C. Ensure that the knot can be quickly released: Using a quick-release knot, such as a half bow or slip knot, is essential to ensure the nurse can rapidly remove the restraints in an emergency, such as sudden respiratory distress or circulatory compromise.
D. Tie the knot with a double turn or square knot: Square knots are secure but not quick to release. In contrast, safety guidelines recommend quick-release knots for client restraints to allow for prompt intervention.
Correct Answer is D
Explanation
A. Recommend that he avoid fast food restaurants until he is familiar with his prescribed diet: Restricting social activities can lead to feelings of isolation and negatively affect adherence. It does not teach the adolescent practical skills for managing diabetes in real-life situations.
B. Encourage him to find activities to do with his friends that do not involve eating: While alternative activities are beneficial, avoiding meals with friends is not realistic for a teen. The goal is to promote self-management skills, not complete avoidance of social situations.
C. Advise him to take his own food with him when going to fast food restaurants with his friends: Bringing food may help in some situations, but it does not encourage the adolescent to make informed choices or learn how to navigate typical social eating environments.
D. Assist him in identifying popular fast foods that are within his meal plan for diabetes: Teaching the teen how to select appropriate options from common fast food menus empowers him to adhere to his diet while maintaining social interactions. This approach promotes self-management, independence, and realistic coping strategies.
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