A client who had a surgical fractured femur repair reports new-onset shortness of breath and increased respirations. What is the nurse’s first action?

Place the client in a high-Fowler position.

Document the client’s oxygen saturation level.

Start oxygen therapy at 2 L/min via nasal cannula.

Contact the primary health care provider.

Answer and Explanation

The Correct Answer is B

Choice A reason: Placing the client in a high-Fowler position may improve breathing but does not assess the cause of shortness of breath. Post-femur repair, pulmonary embolism (PE) is a risk due to fat emboli or thromboembolism, requiring objective data like oxygen saturation first.
Choice B reason: New-onset shortness of breath and tachypnea post-femur repair suggest possible pulmonary embolism or fat embolism syndrome. Documenting oxygen saturation provides objective data to assess hypoxia severity, guiding urgent interventions and communication with the healthcare provider for suspected life-threatening conditions.
Choice C reason: Starting oxygen therapy assumes hypoxia without confirmation. While it may be needed, assessing oxygen saturation first ensures the intervention is appropriate. Unwarranted oxygen administration could delay critical diagnostic steps for conditions like pulmonary embolism, which require anticoagulation or other therapies.
Choice D reason: Contacting the provider is important but secondary to assessing oxygen saturation, which provides critical data to report. Without objective findings, the nurse cannot convey the urgency or specifics of the client’s condition, potentially delaying life-saving interventions for suspected embolism.

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Correct Answer is ["B","C","E"]

Explanation

Choice A reason: Anorexia is not a hallmark late sign of RA. It may occur early due to systemic inflammation but is less specific in late stages, where joint damage and systemic complications like Felty syndrome dominate.
Choice B reason: Felty syndrome, a late RA complication, involves neutropenia, splenomegaly, and recurrent infections due to chronic immune activation. It occurs in long-standing RA, reflecting severe disease progression, making it a key late finding.
Choice C reason: Joint deformity (e.g., swan-neck, boutonniere) is a classic late RA sign due to chronic synovial inflammation eroding cartilage and bone, causing joint instability and deformation, significantly impacting function in advanced disease.
Choice D reason: Low-grade fever is an early RA symptom due to systemic inflammation but typically diminishes in late stages. Chronic joint damage and systemic complications are more prominent, making fever less characteristic of late RA.
Choice E reason: Weight loss is a late RA sign due to chronic inflammation, increased metabolic demand, and cytokine activity (e.g., TNF-alpha). It reflects disease severity and systemic impact, common in advanced RA with joint destruction.

A. Positioning the child with hips flexed 90 degrees at all times. B. Keeping the weights in contact with the floor. C. Checking for skin irritation from traction equipment. D. Releasing the weights on a schedule.

Correct Answer is C

Explanation

Choice A reason: Positioning with hips flexed at 90 degrees is inappropriate for Buck’s traction, which is a skin traction applied to the lower leg to align fractures. Excessive hip flexion can disrupt traction alignment and increase discomfort or complications.
Choice B reason: Weights in Buck’s traction must hang freely to maintain constant force for fracture alignment. Contact with the floor negates the traction’s effect, risking bone misalignment and delayed healing, making this an incorrect care practice.
Choice C reason: Checking for skin irritation is critical in Buck’s traction, as prolonged pressure from straps or bandages can cause pressure ulcers or skin breakdown. Regular skin assessment ensures early detection and prevention of complications, maintaining the traction’s safety and efficacy.
Choice D reason: Releasing weights disrupts the continuous force needed for fracture alignment in Buck’s traction. This can lead to bone displacement, increased pain, or delayed healing, making scheduled weight release an inappropriate and harmful practice.

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A client who had a surgical fractured femur repair reports new-onset shortness of breath and increased respirations. What is the nurse’s first action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses a client with long-term rheumatoid arthritis (RA) for late signs and symptoms. Which assessment findings will the nurse document as late signs and symptoms of RA? (Select all that apply)

Correct Answer is ["B","C","E"]

Explanation

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Correct Answer is C

Explanation

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