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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

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

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale:

Shellfish allergies are not a contraindication to receiving the influenza vaccine. The vaccine contains no shellfish-derived ingredients.

Choice B rationale:

Egg allergies are a contraindication to receiving the influenza vaccine. Traditionally, most influenza vaccines are prepared using eggs and can provoke allergic reactions in individuals allergic to eggs. However, individuals with a mild egg allergy can often receive the vaccine under medical supervision. It is crucial to assess the severity of the egg allergy and consult with an allergist or immunologist before administering the vaccine.

Choice C rationale:

Gelatin allergies are generally not a contraindication to receiving the influenza vaccine. While some vaccines contain gelatin, it is not a component of all influenza vaccines. If the specific vaccine being administered contains gelatin, it should be avoided in individuals with a gelatin allergy.

Choice D rationale:

Milk allergies are not a contraindication to receiving the influenza vaccine. Milk or dairy products are not typically included in the influenza vaccine formulation.

A. Pink, frothy sputum B. Bradycardia C. Flushed, dry skin D. Wheezing

Correct Answer is A

Explanation

- A. Pink, frothy sputum is a characteristic finding of pulmonary edema, which is caused by fluid accumulation in the alveoli and interstitial spaces of the lungs. This impairs gas exchange and leads to hypoxia and respiratory distress.

- B. Bradycardia is not expected in pulmonary edema. The client is more likely to have tachycardia due to increased sympathetic stimulation and decreased cardiac output.

- C. Flushed, dry skin is not expected in pulmonary edema. The client is more likely to have pale, cool, and clammy skin due to peripheral vasoconstriction and decreased perfusion.

- D. Wheezing is not a specific finding of pulmonary edema. It may indicate bronchospasm or asthma, which are different conditions that affect the airways rather than the alveoli.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client for allergies prior to administering the influenza vaccine.The nurse should identify that an allergy to which of the following foods is a contraindication to receiving this vaccine?

Correct Answer is B

Explanation

A nurse is assessing a client who has pulmonary edema. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is teaching a client who has a new prescription for total parenteral nutrition through a central line. Which of the following information should the nurse include in the teaching?

A nurse in the emergency department is assessing a preschooler who has a facial laceration. The nurse should identify which of the following findings as a potential indication of child sexual abuse?

A nurse administers an incorrect dose of medication to a client. The nurse recognizes the error immediately and completes an incident report. Which of the following facts related to the incident should the nurse document in the client's medical record?

A nurse is caring for a school-age child who is taking valproic acid. The nurse should expect the provider to order which of the following diagnostic tests?

A nurse is creating an incident report due to an accidental omission of a client's dressing change during the previous shift. Which of the following statements should the nurse document on the incident report form?

A hospice nurse is consulting with a client and her family about receiving home services. Which of the following statements should the nurse identify as an indication that the family understands home hospice care?

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?

A nurse is teaching about safe handling of formula to a client who is postpartum and chooses to bottle feed her newborn.Which of the following statements by the client indicates an understanding of the teaching?