A nurse is caring for a client diagnosed with a fractured left tibia and fibula. Which data should the nurse report to the healthcare provider immediately?

Localized edema and discoloration occurring hours after the injury

Pain relieved after taking 4 mg of hydromorphone

Pedal pulses cannot be located with a Doppler and complaints of increasing pain

Generalized weakness and pain at the site of injury

Answer and Explanation

The Correct Answer is C

A. Localized edema and discoloration are expected findings after a fracture and do not typically require immediate reporting unless they are accompanied by signs of compartment syndrome or other complications.

B. Pain relieved by hydromorphone indicates that the pain is being effectively managed. This does not require immediate reporting to the healthcare provider.

C. The absence of pedal pulses, even with the use of a Doppler, combined with increasing pain, is a critical finding that suggests compromised circulation, possibly due to compartment syndrome. This is a medical emergency requiring immediate intervention to prevent permanent tissue damage or loss of the limb.

D. Generalized weakness and pain at the site of injury are common findings after a fracture and do not indicate an urgent complication unless associated with other concerning symptoms.

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Correct Answer is D

Explanation

A. Increasing fluid intake may help with hydration, but it is not the most appropriate intervention for a patient whose peak flow rates are significantly low. The priority is to address the asthma exacerbation.

B. Scheduling a follow-up appointment in two weeks is not appropriate in this situation. The patient is experiencing significant symptoms, and immediate action is required to manage the exacerbation.

C. Advising the patient to avoid all physical activity may not be necessary. Physical activity can be adjusted based on the patient's condition, but the priority is to treat the asthma exacerbation and improve the patient's respiratory status.

D. Initiating an asthma action plan and providing oral corticosteroids is the correct approach. A peak flow rate consistently at 45% of the personal best indicates poor asthma control, and the patient likely requires additional treatment, such as oral corticosteroids, to manage the exacerbation. The asthma action plan should guide further management based on the patient's peak flow rate and symptoms.

A. The patient inhales and exhales quickly through pursed lips. B. The patient inhales deeply through the nose and exhales quickly through pursed lips. C. The patient inhales deeply through the nose and exhales slowly through pursed lips. D. The patient inhales deeply through pursed lips and exhales quickly through the nose.

Correct Answer is C

Explanation

A. Inhaling and exhaling quickly through pursed lips does not achieve the intended purpose of pursed-lip breathing. This technique is designed to promote slower, controlled breathing to prevent airway collapse and improve oxygen exchange.

B. Exhaling quickly through pursed lips negates the benefits of pursed-lip breathing. The purpose of this technique is to prolong exhalation, reducing air trapping and improving ventilation.

C. Inhaling deeply through the nose and exhaling slowly through pursed lips is the correct technique for pursed-lip breathing. This method helps maintain open airways, reduces dyspnea, and promotes relaxation.

D. Inhaling deeply through pursed lips and exhaling quickly through the nose is not consistent with proper pursed-lip breathing. The inhalation should be through the nose, and exhalation should be slow and controlled through pursed lips.

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A nurse is caring for a client diagnosed with a fractured left tibia and fibula. Which data should the nurse report to the healthcare provider immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with asthma presents with daily peak flow rates consistently at 45% of their personal best. What is the most appropriate action the nurse should take?

Correct Answer is D

Explanation

The nurse teaches a patient with chronic obstructive pulmonary disease (COPD) about pursed-lip breathing (PLB). Which action by the patient would indicate to the nurse that no further teaching is needed?

Correct Answer is C

Explanation

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