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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The maximum daily dose of acetaminophen for adults is typically 4000 mg to avoid hepatotoxicity. A statement indicating 5000 mg suggests a misunderstanding, as exceeding 4000 mg increases the risk of liver damage due to the accumulation of toxic metabolites like N-acetyl-p-benzoquinone imine, which depletes glutathione.
Choice B reason: Regular liver function tests are recommended for clients on long-term acetaminophen to monitor for hepatotoxicity, as the drug is metabolized by the liver. This statement shows correct understanding, as it acknowledges the need to assess liver enzymes like ALT and AST for potential damage.
Choice C reason: Checking other medications for acetaminophen content is crucial to prevent unintentional overdose, which can lead to acute liver failure. This statement reflects proper understanding, as combination drugs (e.g., cold remedies) often contain acetaminophen, contributing to cumulative toxicity if not monitored.
Choice D reason: Using topical patches or creams for osteoarthritis pain is a valid adjunctive therapy. These deliver localized relief (e.g., NSAIDs or capsaicin) without systemic effects, complementing acetaminophen’s action. This statement indicates correct understanding of multimodal pain management strategies.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A reason: Early ambulation post-hip arthroplasty promotes venous blood flow, reducing stasis, a key factor in Virchow’s triad for thromboembolism. Muscle contractions enhance circulation, preventing clot formation in deep veins, significantly lowering the risk of pulmonary embolism.
Choice B reason: Fluid restriction does not prevent venous thromboembolism and may increase blood viscosity, promoting clot formation. Adequate hydration supports circulation, reducing stasis, making fluid restriction counterproductive for preventing thromboembolism in postoperative clients.
Choice C reason: Quadriceps-setting exercises activate muscle pumps in the legs, promoting venous return and reducing blood stasis. This mechanical action prevents clot formation in deep veins, making it an effective intervention to lower thromboembolism risk post-surgery.
Choice D reason: Compression stockings/devices apply external pressure, enhancing venous return and preventing blood pooling in the legs. This reduces stasis, a major risk factor for deep vein thrombosis, making them a standard preventive measure post-hip arthroplasty.
Choice E reason: Anticoagulants (e.g., heparin) inhibit clot formation by interfering with the coagulation cascade, reducing the risk of thromboembolism. They are critical post-hip arthroplasty, as surgery increases clotting risk due to endothelial damage and immobility.
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