A client reports pain worsening in their right forearm, rating the pain as 7 on a scale of 0 to 10. The client also states their right hand is "tingly.”. The client is able to move their fingers.
The client is avoiding eye contact with staff and is more withdrawn.
The client's adult child is at the bedside.
The client appears drowsy and less alert, but is oriented to person, place, time, and situation.
The client's apical pulse is regular, and their lungs are clear to auscultation.
A report is given to the operating room nurse, and the client is en route to the surgical suite via gurney for repair of a right radial fracture.
Encourage the client to ambulate to the bathroom.
Check the client's peripheral pulses and capillary refill.
Elevate the client's arm above the level of the heart.
Administer a sedative to help the client relax.
The Correct Answer is B
Choice A rationale
Encouraging the client to ambulate to the bathroom would be inappropriate and potentially harmful. The client is experiencing worsening pain, tingling, and is on a gurney en route to surgery for a fractured radius. Ambulation could exacerbate the injury, increase pain, and risk further complications. Mobility should be restricted until the fracture is stabilized and the client is post-operative.
Choice B rationale
This is the correct action as it assesses for potential complications of compartment syndrome, a critical and urgent condition. The worsening pain and tingling are classic symptoms. Compartment syndrome occurs when pressure builds within the fascial compartments, compromising circulation. A loss of peripheral pulses and delayed capillary refill are late signs of impaired circulation and are key indicators for this limb-threatening emergency.
Choice C rationale
Elevating the arm above the heart would decrease arterial blood flow to the injured extremity, which could worsen tissue perfusion and potentially lead to ischemia. For a client with a suspected circulatory compromise, such as with compartment syndrome, the arm should be kept at the level of the heart to maintain adequate blood flow.
Choice D rationale
Administering a sedative could mask the client's symptoms, particularly the level of pain and changes in mental status, which are crucial indicators of their deteriorating condition. The client's pain is a vital sign that needs to be continuously monitored, and sedation would hinder the nurse's ability to accurately assess for changes in their neurovascular status. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
This 12-year-old child with cystic fibrosis and difficulty clearing secretions is the priority. Cystic fibrosis causes thick mucus to accumulate in the lungs, leading to airway obstruction. Inability to clear these secretions indicates a potential acute respiratory crisis, which can rapidly progress to respiratory failure. This is a life-threatening airway and breathing emergency requiring immediate assessment and intervention to prevent respiratory compromise.
Choice B rationale
A 3-year-old with an atrial septal defect and a heart rate of 120/min is a non-acute finding. A heart rate of 120/min is within the normal range for a toddler (90-140/min) and is a common physiological response in a child with a heart defect to maintain cardiac output. This child is stable and does not present with an immediate life-threatening condition.
Choice C rationale
A 2-year-old with diarrhea and abdominal pain is a non-acute finding. While these symptoms require attention, they are common in toddlers and do not typically represent an immediate life-threatening emergency unless accompanied by signs of severe dehydration or septic shock. Other children with respiratory issues take priority due to the higher potential for rapid decompensation.
Choice D rationale
A 5-year-old with type 1 diabetes mellitus and a blood sugar of 150 mg/dL is stable. A blood sugar of 150 mg/dL is within a safe, controlled range for a child with type 1 diabetes, which is typically 80-180 mg/dL. This child does not require immediate intervention as their blood glucose is not indicative of hypo- or hyperglycemia crises. .
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: Corn and black beans are naturally gluten-free. They do not contain the storage proteins found in wheat, barley, or rye that trigger the autoimmune response in celiac disease.
Choice B rationale: Barley contains secalin, a type of gluten protein. Ingesting barley causes inflammatory damage to the intestinal villi in patients with celiac disease and must be strictly avoided.
Choice C rationale: Whole wheat contains gliadin, the primary gluten component. This protein triggers an immune-mediated toxic effect on the small intestine, leading to malabsorption and GI distress in affected children.
Choice D rationale: Rye contains gluten proteins that are harmful to those with celiac disease. Additionally, processed meats like bologna often contain hidden gluten as a thickening agent or filler.
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