A nurse is caring for a client who has a fractured right femur.

Exhibits

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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. To prevent infection and ensure proper healing, it's usually advised to avoid submerging the catheterization site in water until it has adequately healed.

B. There is generally no need for a special diet such as a clear liquid diet following cardiac catheterization unless specified for other reasons.
C. Following cardiac catheterization, it's important to keep the pressure dressing in place to ensure proper healing and prevent bleeding from the catheterization site. Typically, the dressing is removed the next day under safe, controlled conditions.
D. Typically, children can return to school within a few days after cardiac catheterization unless complications arise or there are other specific medical advisories.

A. Eat a light snack before bedtime. B. Perform exercises prior to bedtime. C. Stay in bed at least 1 hr if unable to fall asleep. D. Take a 1-hr nap during the day.

Correct Answer is A

Explanation

A. Eating a light snack before bedtime can help promote sleep by preventing hunger- related awakenings without causing discomfort or indigestion.
B. Performing exercises prior to bedtime may increase alertness and make it more difficult to fall asleep.
C. Remaining in bed for extended periods if unable to fall asleep can worsen insomnia by reinforcing the association between the bed and wakefulness.
D. Taking a long nap during the day can disrupt nighttime sleep patterns and make it more difficult to fall asleep at night.

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A nurse is caring for a client who has a fractured right femur. Exhibits Select the 4 findings on day 2 that require immediate follow-up.

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Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching for the guardian of a school-age child following a cardiac catheterization. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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A nurse is caring for a client who has a fractured right femur.

Exhibits

Select the 4 findings on day 2 that require immediate follow-up.