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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
- A. Diarrhea is not an adverse effect of amitriptyline, which is a tricyclic antidepressant (TCA). Diarrhea may be caused by other factors, such as infection, food intolerance, or stress. Therefore, this choice is incorrect.
- B. Frequent urination is not an adverse effect of amitriptyline either. Frequent urination may be a sign of diabetes, urinary tract infection, or other conditions that affect the kidneys or bladder. Therefore, this choice is also incorrect.
- C. Excessive salivation is not an adverse effect of amitriptyline as well. Excessive salivation may be due to increased production of saliva, difficulty swallowing, or mouth irritation. Therefore, this choice is incorrect too.
- D. Blurred vision is an adverse effect of amitriptyline and other TCAs. Amitriptyline can cause anticholinergic effects, such as dry mouth, constipation, urinary retention, and blurred vision. These effects are more pronounced in older adults and can impair their daily functioning and quality of life. Therefore, this choice is correct and the nurse should identify it as an adverse effect of the medication.
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