A patient has had surgical reduction of an open fracture of the right radius this morning. Which assessment findings should the nurse report immediately to the health care provider?
Right arm muscle spasms
Temperature of 99.9°F (37.7°C)
Loss of the right radial pulse
Pain with right arm movement
The Correct Answer is C
Choice A reason: Right arm muscle spasms may be uncomfortable but are not as critical as circulatory issues.
Choice B reason: A temperature of 99.9°F (37.7°C) is slightly elevated but not immediately alarming post-surgery.
Choice C reason: Loss of the right radial pulse could indicate a serious complication such as compartment syndrome, which requires urgent atention.
Choice D reason: Pain with arm movement is expected post-surgery but is not as urgent as loss of pulse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: A PR interval of 0.04-0.20 seconds is too broad and includes values that are both below and above the normal range.
Choice B reason: A PR interval of 0.12-0.20 seconds is the established normal range for adults, reflecting proper conduction through the AV node.
Choice C reason: The PR interval being less than half the R-to-R ratio is not a standard measurement for PR intervals and does not provide a specific range.
Choice D reason: A PR interval of 0.08-0.10 seconds is below the normal range and may suggest pre-excitation or an AV nodal (junctional) rhythm.
Correct Answer is A
Explanation
Choice A reason: Evaluating the effectiveness of opioid analgesics is crucial as pain management is a primary concern for patients experiencing a sickle cell crisis.
Choice B reason: Limiting the patient's intake of oral and IV fluids is not recommended as hydration is important for patients with sickle cell crisis to reduce blood viscosity and improve circulation.
Choice C reason: Teaching the patient about high-protein, high-calorie foods is beneficial for long-term management but is not the immediate nursing intervention during a crisis.
Choice D reason: Encouraging ambulation may be part of recovery but is not the primary intervention during an acute sickle cell crisis due to the risk of pain exacerbation.
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