A nurse is collecting data from a client who has a fractured left femur and is in skeletal traction. Which of the following findings should the nurse identify as an indication of fat emboli to report to the provider?
Ecchymosis of the thigh
Serous drainage at the pin site
Chest petechiae
Muscle spasms in the left leg
The Correct Answer is C
Choice A reason: This is an incorrect finding, because ecchymosis of the thigh, or bruising, is not a sign of fat emboli, but a sign of bleeding or hematoma formation due to the fracture or the traction. The nurse should monitor the size and color of the ecchymosis and report any changes to the provider.
Choice B reason: This is an incorrect finding, because serous drainage at the pin site, or clear fluid, is not a sign of fat emboli, but a sign of normal healing or infection. The nurse should assess the amount, color, and odor of the drainage and report any signs of infection, such as purulent drainage, redness, swelling, or pain, to the provider.
Choice C reason: This is the correct finding, because chest petechiae, or small red spots on the chest, are a sign of fat emboli, which are a rare but serious complication of long bone fractures. Fat emboli occur when fat globules from the bone marrow enter the bloodstream and travel to the lungs, causing respiratory distress, hypoxia, and pulmonary edema. The nurse should report any signs of fat emboli, such as chest petechiae, dyspnea, tachypnea, tachycardia, fever, or confusion, to the provider.
Choice D reason: This is an incorrect finding, because muscle spasms in the left leg, or involuntary contractions of the muscles, are not a sign of fat emboli, but a sign of pain, inflammation, or nerve injury due to the fracture or the traction. The nurse should administer analgesics and muscle relaxants as prescribed, and provide comfort measures, such as massage, ice, or elevation, to the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is an incorrect instruction, because it is not necessary to take this medication for the rest of your life to prevent recurrence. Isoniazid is usually taken for 6 to 9 months, or as prescribed by the provider, to treat active TB or latent TB infection.
Choice B reason: This is the correct instruction, because your provider will monitor your liver function while you are taking this medication. Isoniazid can cause hepatotoxicity, which is a serious side effect that can damage the liver and cause jaundice, nausea, vomiting, or abdominal pain.
Choice C reason: This is an incorrect instruction, because you should avoid alcohol intake while you are taking this medication. Alcohol can increase the risk of hepatotoxicity and interfere with the metabolism of isoniazid.
Choice D reason: This is an incorrect instruction, because it is not recommended to take this medication with a meal to increase absorption. Isoniazid should be taken on an empty stomach, at least 1 hour before or 2 hours after a meal, to ensure optimal absorption and effectiveness.
Correct Answer is A
Explanation
Choice A reason: This is the correct meal selection, because chicken breast and corn on the cob are low in cholesterol and saturated fat, which can help lower the risk of heart disease.
Choice B reason: This is an incorrect meal selection, because shrimp and rice are high in cholesterol and refined carbohydrates, which can increase the blood cholesterol and glucose levels.
Choice C reason: This is an incorrect meal selection, because cheese omelet and turkey bacon are high in cholesterol and sodium, which can raise the blood pressure and worsen the cardiac function.
Choice D reason: This is an incorrect meal selection, because liver and onions are high in cholesterol and iron, which can contribute to the formation of plaque and clots in the arteries.
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