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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.

A.

Pedal pulses

B.

Breath sounds

C.

Heart rate

D.

Movement of right foot

E.

Respiratory rate

F.

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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Related Questions

Correct Answer is A

Explanation

A. Wiping the nose instead of blowing it reduces the risk of trauma to the nasal mucosa, which can lead to bleeding, especially in individuals with thrombocytopenia.
B. Removing shoes inside the house is a general hygiene practice and does not specifically address the risk of bleeding associated with thrombocytopenia.
C. Using an enema to manage constipation is unrelated to thrombocytopenia and may not be indicated without further assessment and guidance from healthcare providers.
D. While oral hygiene is important, flossing may increase the risk of gum bleeding in individuals with thrombocytopenia, and its frequency should be discussed with healthcare providers.

Correct Answer is C

Explanation

A. While this may be a risk factor for some behaviors, it is not as strong a predictor of violence as a history of actual violent behavior.
B. Although statistics show higher rates of violence among males, it's not a specific predictor for individual behavior.
C. Previous violent behavior is the strongest predictor of future violence.

Understanding a client's history of violence is critical in assessing risk and planning interventions.

D. While certain types of delusions may increase risk, they are not as definitive in predicting violence as past violent behaviors.

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