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
The adolescent has not voided in 4 hr.
Rationale:
- A. The nurse should not address the parents' concerns and provide education and support, but refer the concerns to the provider to address the concerns about the surgical procedure.
- B. The adolescent's blood pressure is 131/89 mm Hg. This is not a correct answer because this blood pressure is within the normal range for an adolescent and does not indicate any complications or adverse effects from the injury or medication.
- C. The adolescent reports severe pain. This is not a correct answer because the nurse should administer morphine as prescribed for pain relief, but this is not a priority finding that requires immediate intervention or reporting to the provider. The nurse should also monitor the adolescent's pain level and response to medication, and use nonpharmacological methods to reduce pain and anxiety.
- D. Although this may raise concerns about renal injury, it is no a contraindication or cause for delay for the emergency surgical procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Assign the client to a private room with negative air pressure.
Rationale:
- 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.
Correct Answer is C
Explanation
- A. This choice is incorrect because the body temperature does not drop 1 degree 1 week after ovulation. The body temperature rises slightly (about 0.4 to 0.8 degrees Fahrenheit) after ovulation and remains elevated until the next menstrual period.
- B. This choice is incorrect because the body temperature should be taken each morning before getting out of bed or doing any activity. Taking the temperature in the evening can result in inaccurate readings due to variations in daily activities, meals, stress, exercise, etc.
- C. This choice is correct because the body temperature might decrease slightly (about 0.2 degrees Fahrenheit) just prior to ovulation due to a surge in estrogen levels. This dip in temperature can indicate that ovulation is about to occur and that the client should avoid unprotected intercourse if she wants to prevent pregnancy.
- D. This choice is incorrect because the body temperature is not at its highest during menstruation. The body temperature drops at the onset of menstruation due to a decline in progesterone levels and marks the beginning of a new cycle.
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