A nurse is caring for a client who is postoperative following repair of a right femur fracture.
The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Rationale for Correct Answers:
- Constipation: Constipation is a common side effect of opioids like oxycodone due to reduced gastrointestinal motility. This risk is heightened in postoperative clients with decreased mobility and altered routines.
- Oxycodone prescription: The prescribed oxycodone every 3 hours PRN increases the likelihood of opioid-induced constipation. Regular opioid use without a bowel regimen can result in significant discomfort or ileus.
Rationale for Incorrect Answers:
- Dysrhythmias: Although the potassium is at the low-normal end (3.6 mEq/L), it does not yet pose a significant risk for dysrhythmias in a stable client without cardiac history or other electrolyte disturbances.
- Hypoglycemia: The casual glucose level of 120 mg/dL is within normal range and does not indicate a risk for hypoglycemia. There’s no diabetic medication involved that would lower blood glucose unexpectedly.
- Hypovolemia: The client has a steady IV fluid infusion, a dry and intact surgical dressing, and no clinical signs of fluid loss. These findings do not support a risk of hypovolemia at this time.
- Impaired circulation: The neurovascular check reveals normal findings: warm toes, intact movement and sensation, and strong pedal pulses. These results suggest adequate perfusion, not impaired circulation.
- Neurovascular check: Normal neurovascular status (warm toes, movement and sensation intact, 2+ pulses) reflects healthy circulation post-surgery and does not correlate with any acute complications.
- Potassium level: Although 3.6 mEq/L is at the lower end of the normal range, it is still adequate and not linked to any current complications like dysrhythmias without other triggers.
- Glucose level: A casual glucose of 120 mg/dL is not clinically concerning and falls within expected limits. It does not suggest hypo- or hyperglycemia in a non-diabetic postoperative patient.
- Femur dressing: The dry and intact dressing indicates that the surgical site is not actively bleeding or infected. It does not signify any increased risk for a complication such as hypovolemia or impaired healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
A. Hypotension: Clients with cervical spinal cord injuries are at risk for neurogenic shock, which disrupts sympathetic nervous system output. This results in peripheral vasodilation, leading to hypotension and bradycardia, especially in injuries above T6.
B. Polyuria: Polyuria is not typically associated with acute cervical spinal cord injuries. Spinal cord injuries can sometimes lead to issues with bladder control, such as urinary retention or neurogenic bladder, which may manifest as overflow incontinence, not typically polyuria.
C. Hyperthermia: Cervical spinal cord injuries can impair thermoregulation due to autonomic nervous system disruption. The body may have difficulty sweating or adjusting blood flow to the skin, which can result in hyperthermia, especially in warm environments.
D. Absence of bowel sounds: Neurogenic shock and loss of autonomic regulation can lead to decreased gastrointestinal motility, resulting in paralytic ileus. This may present as absent or hypoactive bowel sounds in the acute phase of injury.
E. Weakened gag reflex: High cervical spinal cord injuries can impair cranial nerve function and compromise airway protective reflexes. A weakened gag reflex increases the risk of aspiration and may require airway protection through intubation or suctioning.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
Rationale for Correct Answers:
- Hypokalemia: The child is receiving frequent doses of IV furosemide, a loop diuretic that increases urinary potassium loss, putting them at high risk for hypokalemia which can worsen cardiac instability.
- Digitalis toxicity: The client is on a high-dose digoxin regimen. Hypokalemia potentiates digoxin's effects on the myocardium, increasing the risk for toxicity, especially in pediatric cardiac patients. Symptoms include nausea, dizziness, vomiting and arrhythmias.
Rationale for Incorrect Answers:
- Hypertension: The child's blood pressure is 92/66 mm Hg, which is within the normal pediatric range and does not suggest elevated pressure. Instead, heart failure and diuretics may lead to hypotension.
- Murmur: While murmurs are associated with congenital mitral stenosis, it is a chronic finding, not a new or emergent risk in this acute scenario of worsening heart failure.
- Hypercyanotic spells: These are more common in conditions like Tetralogy of Fallot, not mitral stenosis. The child shows signs of respiratory distress but not cyanotic episodes.
- Fever: The client is afebrile across assessments (36.7°C to 36.9°C), and there are no indications of infection or inflammatory processes at this time.
- Dependent rubor: This is typically seen in peripheral arterial disease, more common in adults. The child’s symptoms are consistent with venous congestion from heart failure, not arterial insufficiency.
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