A nurse is assisting in the care of a client whoThe first action the nurse should take is to followed by. is postoperative following an open reduction internal fixation of the right tibia.
Complete the following sentence by using the lists of options.
The first action the nurse should take is to
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
The first action the nurse should take is to assess neurovascular status followed by notify the provider.
- Assess neurovascular status first: The diminished pulses and coolness of the right foot indicate compromised circulation, requiring immediate evaluation to confirm the severity.
- Notify the provider: Once the critical assessment findings are confirmed, notifying the provider for prompt intervention is essential to prevent further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Keeping both arms below the level of the client's heart is not recommended for preventing lymphedema. The affected arm should be elevated when possible to reduce the risk of fluid accumulation.
B. Obtaining blood pressure readings on the affected arm is contraindicated because it can increase the risk of lymphedema.
C. Use the client's left arm to obtain blood samples: To prevent lymphedema, it's important to avoid using the affected arm (the right arm in this case) for invasive procedures like blood draws or blood pressure measurements, as this can increase the risk of lymphedema by promoting fluid retention.
D. Limiting range-of-motion exercises could impair recovery and muscle function. Early and gentle exercises should be encouraged to maintain mobility and avoid complications.
Correct Answer is D
Explanation
A. Soreness at the incision site: Mild soreness is an expected postoperative finding.
B. Serosanguineous drainage on the dressing: This type of drainage is typical after surgery and not concerning unless it becomes excessive.
C. Report of a sore throat: A sore throat is expected due to intubation during anesthesia and does not indicate a complication.
D. Tingling of the fingers: Tingling of the fingers suggests hypocalcemia due to potential damage to the parathyroid glands during surgery. This is a serious complication and requires immediate evaluation.
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