A nurse on a medical-surgical unit is caring for a client.
Exhibits
Drag words from the choices below to fill in each blank in the following sentence.
The client is at risk for developing dropdown and dropdown
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
The client is at risk for developing pressure injury and foot drop. Given the client's history of a recent cerebrovascular accident (CVA) and the inability to reposition themselves, there is a heightened risk for pressure injuries due to prolonged periods of immobility. Additionally, the observed occasional movement of the left arm and leg with the right side without movement suggests a potential for muscle weakness or paralysis, which can lead to foot drop, characterized by difficulty in lifting the front part of the foot.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Propranolol is a beta-blocker used to control blood pressure and heart rate. However, the nurse has a hold order for propranolol if the apical pulse (heart rate) is less than 50 beats per minute. The nurse documented a heart rate of 42 bpm at 0815, which falls below the hold parameter for propranolol. Administering propranolol in this case could worsen the client's bradycardia (slow heart rate) and therefore requires an incident report.
B. Pantoprazole is a proton pump inhibitor and doesn't have a direct impact on heart rate within the usual therapeutic range.
C. Lovastatin is a cholesterol medication and wouldn't cause a significant drop in heart rate at this dosage.
D. While morphine can slow the heart rate, it's typically used for pain management and may be necessary for the client's comfort. However, the nurse should monitor the respiratory rate closely due to potential respiratory depression.
E. Cefuroxime is an antibiotic and wouldn't significantly affect heart rate.
Correct Answer is D
Explanation
A. Lactated Ringer's does not provide the necessary glucose to prevent hypoglycemia in clients receiving TPN.
B. 3% sodium chloride is hypertonic and not appropriate for preventing hypoglycemia.
C. 0.9% sodium chloride does not provide the necessary glucose.
D. Dextrose 10% in water (D10W) provides a glucose source to help prevent hypoglycemia in clients when TPN is temporarily unavailable.
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