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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.

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Correct Answer is {"dropdown-group-1":"C"}

Explanation

Total calcium 8.0 mg/dL (9.0 to 10.5 mg/dL) is correct.

A. A client who has cellulitis and is receiving oral antibiotics every 8 hr B. A client who is postoperative following an upper endoscopy procedure and is alert but does not have a gag reflex C. A mother and their newborn 12 hr postdelivery D. A client who has lower extremity weakness and is newly admitted for observation

Correct Answer is A

Explanation

A. A client who has cellulitis and is receiving oral antibiotics every 8 hr has a mild to moderate infection that can be managed at home with proper wound care and medication adherence. The client does not require hospitalization unless there are signs of systemic infection or complications.

B. A client who is postoperative following an upper endoscopy procedure and is alert but does not have a gag reflex has a high risk of aspiration and airway obstruction due to impaired swallowing function. The client requires close monitoring and intervention until the gag reflex returns, which can take several hours or longer depending on the type and amount of anesthesia used.

C. A mother and their newborn 12 hr postdelivery have not completed the minimum recommended stay of 24 to 48 hours for uncomplicated vaginal deliveries or 72 to 96 hours for cesarean deliveries, according to the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. The mother and their newborn require assessment, education, support, and follow-up care to ensure their health and well-being.

D. A client who has lower extremity weakness and is newly admitted for observation has an undiagnosed condition that could indicate a serious neurological or vascular problem, such as stroke, spinal cord injury, or peripheral artery disease. The client requires diagnostic testing, evaluation, treatment, and rehabilitation to prevent further deterioration or complications.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 1 day postoperative following a total thyroidectomy. Exhibits Complete the following sentence by using the lists of options. The client is at the highest risk for developing hypocalcemia evidenced by the

Correct Answer is {"dropdown-group-1":"C"}

Explanation

A nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster. Which of the following clients should the nurse recommend for discharge?

Correct Answer is A

Explanation

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