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
Choice Arationale:
Allowing the client to eat meals in his room might not be the best approach. Patients with anorexia nervosa often have distorted body image and may engage in secretive behaviors related to food intake. Supervised meals and observation during and after meals are essential to prevent behaviors like purging.
Choice B rationale:
Weighing the client every 48 hours is not frequent enough for a patient with anorexia nervosa. Daily weight monitoring is crucial in these cases because rapid weight loss or fluctuations can indicate worsening malnutrition, dehydration, or other medical complications.
Choice Crationale:
Obtaining vital signs every other day might not provide an accurate picture of the client's overall health status, especially during the critical early phase of care. In anorexia nervosa, patients are at risk of severe complications such as electrolyte imbalances, cardiac issues, and malnutrition, which can rapidly change and require close monitoring.
Choice D rationale:
Observing the client for 1 hour after meals is a crucial nursing intervention for individuals with anorexia nervosa. After meals, these patients are at risk of engaging in purging behaviors like vomiting or excessive exercise to compensate for caloric intake. Close observation can help prevent these behaviors and ensure the client's safety.
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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