A nurse is assisting with the care of a client.
Exhibits

The nurse is caring for a client who has a hip and pelvis fracture. Select the 4 findings on Day 2 that require immediate follow-up.

Heart rate

Oxygen saturation

Edema

Temperature

Urine color

Pedal pulses

Answer and Explanation

Correct Answer : A,C,E,F

Heart rate: The increase in heart rate from 92/min to 108/min suggests possible complications such as pain, infection, or hypovolemia.

Oxygen saturation: it is within normal range (96%), it doesn’t indicate an immediate problem.

Edema: Increased edema from slight to 2+ suggests worsening of the condition, possibly indicating an underlying issue such as poor circulation or developing compartment syndrome.

Temperature: The slight increase in temperature is not immediately concerning.

rine color: Dark, reddish-brown urine is concerning for possible rhabdomyolysis or other renal issues.

Pedal pulses: Diminished pedal pulses (from +2 to +1) and prolonged capillary refill time (6 seconds) indicate compromised peripheral circulation, which needs immediate attention.

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Correct Answer is B

Explanation

A. Acutely inflamed joints respond best to heat therapy. Heat therapy is generally used to relieve chronic stiffness in RA but acutely inflamed joints typically respond better to cold therapy to reduce inflammation.

B. It’s important to monitor all body systems for effects of the disease. Correct. RA is a systemic autoimmune disease that can affect multiple body systems, not just the joints, unlike osteoarthritis, which is primarily a degenerative joint disease.

C. Exercise is poorly tolerated and frequent rest is needed. While rest is important during acute flare-ups, regular, gentle exercise is crucial in managing RA to maintain joint function and muscle strength.

D. Injury and age are the greatest contributors to disease development. RA is an autoimmune disorder with a different etiology than osteoarthritis, which is more related to wear and tear and aging.

A. "This will help to decrease the frequency of dressing changes." B. "This will improve your ability to ambulate sooner." C. "This will decrease the chance of you experiencing phantom limb pain." D. "Placing this now will improve the fit of the prosthesis."

Correct Answer is B

Explanation

A. "This will help to decrease the frequency of dressing changes." The placement of a prosthesis does not impact the frequency of dressing changes, which are based on wound care needs.

B. "This will improve your ability to ambulate sooner." Early prosthesis placement can aid in quicker rehabilitation and earlier ambulation.

C. "This will decrease the chance of you experiencing phantom limb pain." Prosthesis placement does not necessarily decrease the occurrence of phantom limb pain, which is a common phenomenon after amputation.

D. "Placing this now will improve the fit of the prosthesis." The fit of the prosthesis is more related to the residual limb's healing and shaping, not necessarily the timing of initial placement.

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A nurse is assisting with the care of a client. Exhibits The nurse is caring for a client who has a hip and pelvis fracture. Select the 4 findings on Day 2 that require immediate follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assisting with the care of a patient with rheumatoid arthritis (RA). The nurse must remember in which way RA care is different from osteoarthritis care. What type of nursing care does the nurse specifically provide for the patient with RA?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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A nurse is assisting with the care of a client.
Exhibits

The nurse is caring for a client who has a hip and pelvis fracture. Select the 4 findings on Day 2 that require immediate follow-up.