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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Provide an elevated toilet seat: This is important for preventing hip dislocation but is not the immediate priority.
B. Assist out of bed immediately following surgery: Mobilizing the patient is important to prevent complications such as deep vein thrombosis (DVT) and pneumonia, but this should be done safely and as prescribed.
C. Medicate with pain medications: Pain management is crucial for postoperative recovery but is part of comprehensive care rather than the single priority.
D. Maintain weight bearing as prescribed: Following weight-bearing restrictions is critical to ensure proper healing and prevent complications such as dislocation or prosthetic failure. This is the immediate priority in terms of preventing harm and ensuring recovery.
Correct Answer is C
Explanation
A. It increases formation of purines. Increasing purine formation would exacerbate gout by increasing uric acid levels.
B. It increases metabolism of purines. Allopurinol does not increase the metabolism of purines.
C. It blocks formation of uric acid. Allopurinol works by inhibiting xanthine oxidase, an enzyme involved in the production of uric acid, thereby reducing uric acid levels in the body.
D. It excretes protein. Allopurinol does not promote protein excretion; it specifically targets uric acid metabolism.
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