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 C
Explanation
A. Referring the family to a chronic pain support group may be beneficial but does not address the immediate need to assess the child's current condition and management.
B. Requesting a change in medication from the provider may be necessary but should be based on a thorough assessment, including reviewing the child's pain diary.
C. Reviewing the child's electronic pain diary allows the nurse to gather important information about the frequency, severity, triggers, and effectiveness of current interventions for migraine headaches, guiding further assessment and management.
D. While involving the school nurse may be part of the child's care plan, it does not address the immediate need to assess the child's current condition and management.
Correct Answer is B
Explanation
A. Suspiciousness of others is more characteristic of paranoid personality disorder.
B. Preoccupation with aging is a common characteristic of narcissistic personality disorder. Individuals with this disorder often have an exaggerated sense of self- importance, a need for admiration, and a lack of empathy for others. Concerns about aging may stem from a fear of losing their perceived attractiveness or power.
C. Exhibiting separation anxiety is not typically associated with narcissistic personality disorder.
D. Ritualistic behavior may be seen in obsessive-compulsive personality disorder but is not a defining feature of narcissistic personality disorder.
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