The nurse is preparing a client for surgery who was admitted to the emergency center following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin sodium 5,000 units subcutaneously daily. What is the priority nursing action?

Have the client sign the surgical and transfusion permits.

Ensure that the potential for bleeding is explained to the client

Observe the heparin injections sites for signs of bruising.

Notify the healthcare provider of the client's medication history.

Answer and Explanation

The Correct Answer is D

A. Have the client sign the surgical and transfusion permits:
While obtaining signed consent is important, the immediate concern is addressing the client's medication history, especially the use of heparin, which can contribute to bleeding.

B. Ensure that the potential for bleeding is explained to the client:
Education about the potential for bleeding is important, but the immediate action is to communicate the client's medication history to the healthcare provider for appropriate guidance.

C. Observe the heparin injection sites for signs of bruising:
Monitoring for bruising at injection sites is a consideration, but it is not the priority when the client is actively bleeding from an open fracture.

D. Notify the healthcare provider of the client's medication history:
This is the correct answer. Heparin is an anticoagulant, and its use can increase the risk of bleeding during surgery. The healthcare provider needs to be informed of the client's current medication history to make decisions regarding the timing and management of heparin therapy in the perioperative period.

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Correct Answer is A

Explanation

A. Discuss approaches to chronic pain control with the client:
This is the correct answer. Heberden's nodes are bony enlargements that can occur in osteoarthritis, particularly in the joints of the fingers. These nodes can be associated with pain. Discussing approaches to chronic pain control with the client is an appropriate nursing intervention to address the client's pain and improve quality of life.

B. Review the client's dietary intake of high-protein foods:
Dietary intake of high-protein foods is not directly related to the management of Heberden's nodes in degenerative joint disease. Pain control and joint protection measures are more relevant.

C. Notify the healthcare provider of the finding immediately:
While it's important to communicate significant findings to the healthcare provider, the presence of Heberden's nodes in degenerative joint disease may not require immediate notification unless there are other concerning symptoms or complications.

D. Assess the client's radial pulses and capillary refill time:
Assessing radial pulses and capillary refill time is not directly related to managing Heberden's nodes in degenerative joint disease. These nodes are primarily a result of joint changes in osteoarthritis.

A. Assess client for signs and symptoms of upper airway infection. B. Determine if the client is using an inhaler before exercising. C. Teach client to use pursed lip breathing when episodes occur. D. Review the client's routine asthma management prescriptions

Correct Answer is D

Explanation

A. Assess client for signs and symptoms of upper airway infection:
While upper airway infections can contribute to respiratory symptoms, the client's history of asthma and the exacerbation of symptoms during exercise suggest that asthma management should be a priority.

B. Determine if the client is using an inhaler before exercising:
This is a relevant consideration, and ensuring proper pre-exercise use of bronchodilators (such as an inhaler) is an important aspect of asthma management. However, the question is broader and involves a review of the client's overall asthma management.

C. Teach client to use pursed lip breathing when episodes occur:
Pursed lip breathing is a technique that can help manage symptoms, especially during episodes of bronchoconstriction. However, the focus here is on a more comprehensive assessment and review of the client's routine asthma management.

D. Review the client's routine asthma management prescriptions:
This is the correct answer. The client's reported symptoms during exercise suggest a potential need for adjustments to the routine asthma management plan. Reviewing the client's prescriptions, including the type and timing of medications, can help ensure optimal control of symptoms, especially during physical activity.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences on the client's fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse take?

Correct Answer is A

Explanation

A client with a history of asthma reports having episodes of bronchoconstriction and increased mucous production while exercising. Which action should the nurse implement?

Correct Answer is D

Explanation

Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first?

The nurse is evaluating a client's understanding of diet teaching about the DASH (Dietary Approaches to Stop Hypertension) eating plan. Which behavior indicates that the client is adhering to the eating plan?

The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding?

A client with lung cancer who wears a subcutaneous morphine sulfate patch for pain is short of breath and is difficult to arouse. When performing a head to toe assessment, the nurse discovers four analgesic patches on the client's body. Which intervention should the nurse implement first?

The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?