A nurse is caring for a client who has a fractured right femur.
Select the 4 findings on day 2 that require immediate follow-up.
Pedal pulses
Breath sounds
Heart rate
Movement of right foot
Respiratory rate
Pulse oximetry
Correct Answer : B,C,E,F
A. While it's important to assess pedal pulses regularly, there is no indication in the scenario that the pedal pulses are abnormal or require immediate follow-up. The description mentions bilateral pedal pulses being present and intact throughout both days, suggesting no acute issues with peripheral circulation.
B. Crackles heard at the bases indicate possible pulmonary complications such as atelectasis or pneumonia, requiring further assessment and intervention.
C. A heart rate of 112/min indicates tachycardia, which could be a sign of pain, anxiety, or underlying cardiovascular issues. Further evaluation is needed to determine the cause.
D. The scenario states that the movement and sensation of the right foot are intact, with warm skin and no change in pigmentation. There are no signs of compromised neurovascular status in the right foot based on the provided information, so immediate follow-up for this finding is not necessary.
E. A respiratory rate of 28/min is elevated, suggesting respiratory distress or inadequate ventilation. Prompt assessment and intervention are necessary to address any respiratory issues.
F. A pulse oximetry reading of 88% on room air indicates hypoxemia, which requires immediate attention to ensure adequate oxygenation. Further assessment and intervention are needed to improve oxygen saturation levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Documenting the transfusion reaction in the medical record is essential for accurate documentation and communication among the healthcare team.
B. Administering epinephrine subcutaneously is not indicated for febrile transfusion reactions. It is instead indicated for anaphylaxis.
C. Infusing lactated Ringer's IV may be indicated for managing transfusion reactions, but the specific treatment depends on the type and severity of the reaction. It's essential to consult with the healthcare provider for appropriate interventions.
D. Placing the blood bag in a biohazard bag before discarding is a routine procedure for disposing of blood products but is not the immediate priority when managing a transfusion reaction.
Correct Answer is ["A","B","C"]
Explanation
The presence of more frequent headaches and difficulty sleeping, coupled with a significant increase in blood pressure (BP 169/91 mm Hg), could suggest potential adverse effects of the medication phenelzine, which is known to cause headaches and hypertensive reactions. It is crucial for the nurse to monitor these symptoms closely, as they may require medical attention and could indicate the need for an adjustment in the client's treatment plan. The client's vital signs should be regularly monitored, and any new or worsening symptoms should be reported to the healthcare provider promptly to ensure the client's safety and well-being.
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