The nurse is assessing a client who recently returned from surgery for a femur fracture. The client begins to complain of pain, numbness, and tingling to the affected extremity. Upon assessment, the extremity is cold to the touch with no pedal pulse and no motor function. Which of the following actions should the nurse take? (Select all that apply)

Apply a constricting bandage/gauze wrap

Advise the client they will need an immediate amputation

Prepare the client to go back to the operating room

Elevate the extremity and apply ice

Notify the surgeon

Answer and Explanation

Correct Answer : C,E

A. Applying a constricting bandage/gauze wrap is contraindicated. This could further compromise circulation and exacerbate ischemia.
B. Advising the client about an immediate amputation is inappropriate and outside the nurse's scope of practice. The focus should be on timely intervention and notifying the surgeon.
C. Preparing the client to go back to the operating room is appropriate because the symptoms indicate potential compartment syndrome or vascular compromise, which often requires surgical intervention to restore circulation.
D. Elevating the extremity and applying ice is contraindicated in this scenario. Elevation can further decrease blood flow to an already ischemic limb, and ice application can cause vasoconstriction, worsening the issue.
E. Notifying the surgeon is essential. The described symptoms are a surgical emergency requiring immediate evaluation and intervention to prevent permanent damage.

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Correct Answer is B

Explanation

A. Administration of IV antibiotics is not appropriate for this client, as there is no indication of an infection. The client's symptoms are consistent with fluid overload due to heart failure, not an infectious process.
B. Administration of IV diuretics is the priority intervention. The client is exhibiting signs of fluid overload, including jugular venous distention, crackles, and a bounding pulse. IV diuretics, such as furosemide, help reduce fluid volume, alleviate pulmonary congestion, and improve breathing.
C. Isotonic intravenous fluids would exacerbate the fluid overload and worsen the client's symptoms. This intervention is contraindicated in this scenario.
D. Laying the client supine with legs elevated is inappropriate for a client with heart failure and fluid overload, as it can increase venous return to the heart and worsen pulmonary congestion. Instead, the client should be positioned upright to improve breathing.

A. Hypertonic fluids are contraindicated in patients with cerebral edema. B. Hypertonic saline may be administered to shift fluid out of brain tissue. C. Hypertonic saline is most often used for clients in hypernatremia. D. Hypertonic fluids are administered to promote increased brain tissue hydration.

Correct Answer is B

Explanation

A. Hypertonic fluids are not contraindicated in patients with cerebral edema. In fact, they are often used to reduce cerebral swelling by drawing fluid out of the brain tissue into the bloodstream.
B. Hypertonic saline (3%) is used to shift fluid out of brain tissue in conditions such as cerebral edema. It creates an osmotic gradient, pulling water from the intracellular space into the extracellular and vascular compartments, reducing intracranial pressure.
C. Hypertonic saline is not used for clients with hypernatremia because it would exacerbate the condition by further increasing sodium levels.
D. Hypertonic fluids do not promote hydration of brain tissue. Instead, they work to reduce excess fluid in the brain by creating an osmotic effect.

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Which of the following statements regarding hypertonic (3%) sodium chloride is correct?

Correct Answer is B

Explanation

The nurse in a clinic is reviewing laboratory results for a patient suspected of having undiagnosed diabetes mellitus. Which of the following results would be diagnostic for diabetes?

A nurse is preparing to administer 40 mEq of potassium chloride in 45% sodium chloride (NaCl) 500 mL IV to infuse 10 mEq/hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

The nurse is reviewing laboratory results for a client admitted for renal failure and notes the following: Sodium 144 mEq/L and Potassium 6.6 mEq/L. Which of the following should be the priority intervention?

The nurse is caring for a client who is diabetic and has a blood glucose level of 30 mg/dL. The client is unconscious and has a 20-gauge peripheral IV in the antecubital area. After securing the client's airway, what medication should the nurse plan to administer first?

The nurse is caring for a client with external fixation of the tibia. Which of the following would the nurse include in the plan of care?

The nurse is caring for a client who was admitted for a closed femur fracture. Which of the following signs and symptoms would alert the nurse that the client is experiencing compartment syndrome?

The nurse is providing education to a client newly diagnosed with gastroesophageal reflux disease (GERD). The nurse knows that the teaching was effective when the client states they should eat which of the following foods?

Which of the following interventions should the nurse include when caring for a client who is returning from surgery for an above-the-knee amputation?