Patient Data

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.

Provide morphine 2 mg IV push (IVP).

Inspect the bandage for drainage.

Check capillary refill on bilateral upper extremities.

Answer and Explanation

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

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Correct Answer is []

Explanation

Rationale for Correct Choices:

• Extrapyramidal reaction: The client exhibits muscle stiffness, constant leg shaking, forward-backward rocking, and abnormal head positioning, all of which are hallmark signs of extrapyramidal symptoms (EPS) often caused by antipsychotic medications like haloperidol and chlorpromazine. Recognizing EPS early prevents further complications such as severe dystonia or Parkinsonism.

• Initiate one-on-one observation: Continuous observation is essential to ensure client safety, particularly due to agitation, abnormal movements, and risk of injury from dystonia or uncontrolled motor activity, which can be exacerbated in psychiatric patients on antipsychotics.

• Education on administration and side effects of haloperidol: Teaching the client and caregivers about haloperidol’s potential side effects, including EPS, akathisia, and tardive dyskinesia, enhances adherence, promotes early reporting of adverse effects, and supports safe medication management.

• Gait and muscle strength: Monitoring gait and muscle strength allows the nurse to track the severity and progression of extrapyramidal symptoms, assess mobility limitations, and evaluate the effectiveness of interventions like anticholinergic medications or dosage adjustments.

• Improvement in symptoms: Observing improvement in EPS or agitation provides measurable evidence that interventions are effective, guiding ongoing care and any necessary modifications to therapy or dosing.

Rationale for Incorrect Choices:

• Mucositis: Mucositis involves inflammation and ulceration of the mucous membranes, typically related to chemotherapy or radiation therapy, and is not consistent with this client’s current presentation of abnormal motor activity and psychiatric symptoms.

•Hypertensive crisis: The client’s blood pressure is within a normal to mildly elevated range, and there are no signs of acute end-organ damage, so hypertensive crisis is unlikely in this scenario.

• Parkinson’s Disease: Parkinsonism is a chronic neurodegenerative disorder characterized by resting tremor, bradykinesia, and rigidity, not acute onset EPS triggered by antipsychotic use in a young adult with schizophrenia.

• Institute oral hygiene to prevent candidiasis: Oral hygiene is generally important but does not address the acute neurological side effects of antipsychotic medications, making it nonessential for EPS management.

• Immediate dietician consult: While nutrition is important, it is not immediately relevant for extrapyramidal symptoms and does not address the urgent motor complications caused by antipsychotics.

• Administer antihypertensive: The client’s blood pressure is not critically elevated, and there are no indications of hypertensive emergency, so antihypertensive therapy is unnecessary.

• Blood pressure: Monitoring blood pressure is routine but not directly related to tracking extrapyramidal symptoms or response to antipsychotic therapy in this case.

• Swallowing: While dysphagia can occur in severe EPS, this client does not currently present with swallowing difficulties, making it less critical to monitor compared to gait and muscle strength.

A. Place the client in the Trendelenburg position. B. Remove the client's legs from the stirrups. C. Instruct the client to take deep breaths. D. Place a wedge under the client's hip.

Correct Answer is D

Explanation

A. Place the client in the Trendelenburg position: While this position may increase venous return, it does not address the underlying cause in a pregnant client, which is usually aortocaval compression by the uterus. Simply tilting the table may be less effective than proper lateral displacement.

B. Remove the client's legs from the stirrups: Removing the legs may relieve some discomfort but does not correct the maternal hypotension caused by pressure on the inferior vena cava. Additional interventions are needed to improve circulation.

C. Instruct the client to take deep breaths: Deep breathing may help with anxiety or mild shortness of breath but does not resolve the hemodynamic compromise caused by supine hypotensive syndrome.

D. Place a wedge under the client's hip: Placing a wedge under the right or left hip tilts the uterus off the inferior vena cava, improving venous return, cardiac output, and blood pressure. This is the priority action to relieve dizziness, pallor, and diaphoresis in a pregnant client at 26 weeks’ gestation.

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Patient Data 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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

After placing a client at 26-weeks gestation in the lithotomy position, the client complains of dizziness and becomes pale and diaphoretic. Which action should the nurse implement?

Correct Answer is D

Explanation

The caregiver of a toddler is concerned about the frequency of ear infections and states, "The pediatrician said my child's ear tubes are small and short. What can I do about this?" Which action should the nurse take?

An adult client was diagnosed with stage IV lung cancer three weeks ago. The client's spouse approaches the nurse and asks, "How will I know that my husband's death is imminent? Our two adult children want to be here when their father dies." Which is the best response by the nurse?

A parent brings their child, who has a history of asthma, to the emergency department (ED). The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain?

The nurse is administering multiple prescribed vaccines to a toddler. Which strategy should the nurse prioritize to reduce the duration of pain?

The nurse is caring for a client whose BMI is 35 kg/m². Which condition(s) is/are the client at greatest risk of developing? Select all that apply.

Patient Data

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.