The nurse is continuing to care for the adolescent.

Provider Prescriptions

1415:

X-ray of right leg shows open fracture of the right proximal tibia

Surgery consult

Morphine 4 mg IV every 2 hr as needed for pain.

The nurse is preparing the adolescent for the fasciotomy. Which of the following findings should the nurse report to the provider prior to surgery?

The adolescent's parents have concerns regarding the surgery.

The adolescent's blood pressure is 131/89 mm Hg.

The adolescent reports severe pain.

The adolescent has not voided in 4 hr.

Answer and Explanation

The Correct Answer is A

A. Addressing parental concerns is crucial, especially for informed consent. If the parents are not comfortable or have unresolved questions, it could delay or prevent the surgery from proceeding.

B. While this blood pressure is slightly elevated, it is not an immediate concern that would typically prevent surgery.

C. Although severe pain is important to manage, it may not require immediate reporting unless it is unmanageable or indicates a serious problem.

D. While the lack of voiding in an immobile patient is a concern and could indicate urinary retention, it is not necessarily a finding that would prevent surgery.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason:

Allow the client's partner to translate. While the partner may be well-intentioned, using a family member or friend as an ad-hoc interpreter can compromise the confidentiality of the information and may not accurately convey the client's medical concerns.

Choice B reason:

Have the client's child translate. Relying on a child to translate sensitive medical information is inappropriate, as it may burden the child and may lead to potential misunderstandings or omissions in communication.

Choice C reason:

Ask a nursing student who speaks the same language as the client to translate. Although a nursing student who speaks the same language as the client may be able to assist, using a professional interpreter is the preferred option. Professional interpreters have specific training in medical terminology and communication, ensuring the most accurate and effective exchange of information.

Choice D reason:

Using a professional interpreter is essential in situations where the healthcare provider and the client do not speak the same language. It ensures accurate communication, maintains confidentiality, and prevents misunderstandings. In this scenario, the nurse should request an interpreter who is proficient in the client's language to assist with the admission process.

A. Restrict fresh flowers from the client's room. B. Have visitors maintain a distance of 1.8 m (6 feet) from the client. C. Wear a surgical mask when providing client care. D. Assign the client to a private room with negative air pressure.

Correct Answer is D

Explanation

A. Incorrect. Restricting fresh flowers from the client's room is not necessary for infection control purposes. However, some clients with pulmonary tuberculosis may have hypersensitivity reactions to certain plants or flowers, so the nurse should assess the client's allergies before allowing them in the room.

B. Incorrect. Maintaining a distance of 1.8 m (6 feet) from the client is not sufficient to prevent transmission of tuberculosis. Visitors should also wear a HEPA respirator and limit their contact time with the client.

C. Incorrect. A surgical mask is not adequate to protect the nurse from inhaling airborne droplet nuclei that contain Mycobacterium tuberculosis. The nurse should wear a high-efficiency particulate air (HEPA) respirator when providing client care.

D. Correct. Assigning the client to a private room with negative air pressure is the most effective way to prevent the spread of tuberculosis to other clients and staff members. The room should have at least six air exchanges per hour and an exhaust system that vents directly to the outside.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is caring for a client who has active pulmonary tuberculosis. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include?

Before administering an antibiotic that can cause nephrotoxicity, which laboratory value is most important for the practical nurse (PN) to review?

A nurse is caring for a group of clients. Which of the following clients should the nurse attend to first?

A nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching?

A nurse is admitting a client to the psychiatric unit after attempting suicide. The client states, "My family does not care whether I live or die." Which of the following responses should the nurse make?

A nurse is caring for a client who has acute blood loss following a trauma. The client refuses a blood transfusion that might potentially save their life. Which of the following actions should the nurse take first?