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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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Correct Answer is C

Explanation

Choice A rationale:

Massaging the legs before applying the stockings is not advisable. Vigorous massage can dislodge clots in patients with DVT, leading to serious complications like pulmonary embolism. It is essential to handle the legs gently and follow the proper procedure for applying antiembolitic stockings.

Choice B rationale:

Folding the stockings at the top if they are too long is not recommended. Altering the stockings in this way can create uneven pressure, reducing their effectiveness in preventing DVT. It is crucial to choose the correct size of stockings to ensure proper compression and prevention of complications.

Choice C rationale:

Measuring the legs with a tape measure to determine the stocking size is the correct action. Proper sizing is essential to ensure the stockings fit the patient correctly and provide the appropriate level of compression. Ill-fitting stockings can be ineffective and may even cause harm, such as skin abrasions or impeded circulation.

Choice D rationale:

Removing the stockings every 24 hours is unnecessary unless there is a specific medical indication to do so. Continuous wear of antiembolitic stockings is generally recommended to provide consistent compression and prevent deep-vein thrombosis (DVT)

A. Diarrhea B. Dry mouth C. Photophobia D. Bruising

Correct Answer is B

Explanation

A is incorrect because diarrhea is not an adverse effect of clonidine, but rather a symptom of other conditions such as infection, inflammation, or food intolerance.
B is correct because dry mouth is a common adverse effect of clonidine, which is an alpha-2 adrenergic agonist that reduces sympathetic nervous system activity.
C is incorrect because photophobia, or sensitivity to light, is not an adverse effect of clonidine, but rather a symptom of other conditions such as migraine, eye injury, or infection.
D is incorrect because bruising, or bleeding under the skin, is not an adverse effect of clonidine, but rather a symptom of other conditions such as coagulation disorders, vitamin deficiency, or trauma.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has deep-vein thrombosis and a new prescription for antiembolitic stockings. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who has a new prescription for clonidine. The nurse should inform the client that which of the following findings is an adverse effect of this medication?

Correct Answer is B

Explanation

A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan?

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 has received change-of-shift report on four assigned clients. For which of the following clients should the nurse intervene to prevent a potential food and medication interaction?

A nurse is caring for a 3-year-old toddler who has dehydration.Which of the following findings should the nurse report to the provider?

A community health nurse is providing education to a group of older adults about immunizations.Which of the following immunizations should the nurse recommend?

A nurse is assessing a client who is receiving enteral feedings via an NG tube.The client has developed hyperosmolar dehydration.Which of the following actions should the nurse take when administering the client's feedings?

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