A patient who had open reduction and internal fixation (ORIF) of left lower leg fractures continues to report severe pain in the leg 15 minutes after receiving the prescribed IV morphine.
The nurse determines pulses are faintly palpable and the foot is cool to the touch.
Which action should the nurse take next?

Check the patient's blood pressure.

Notify the health care provider.

Assess the incision for redness.

Reposition the left leg on a pillow.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Checking the blood pressure is not the priority action in this case. The symptoms described may suggest compartment syndrome, which is a medical emergency and requires immediate intervention.

Choice B rationale

The correct action is to notify the health care provider immediately as this may indicate compartment syndrome, a serious complication that can occur after fractures and can lead to permanent damage if not treated promptly.

Choice C rationale

Assessing the incision for redness is not appropriate in this scenario as the symptoms suggest a more severe underlying issue such as compartment syndrome, which requires urgent attention.

Choice D rationale

Repositioning the leg may provide temporary relief but does not address the potential underlying issue of compartment syndrome. The priority is to notify the health care provider.

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Correct Answer is B

Explanation

Choice B rationale

Potassium levels should be reviewed before administering furosemide. Furosemide is a loop diuretic that can cause significant potassium loss through increased urine output. Monitoring potassium is crucial to prevent hypokalemia, which can lead to cardiac arrhythmias and other serious complications.

Choice A rationale

Bicarbonate levels are not directly impacted by furosemide use and are less critical to review in this context. While they are important in assessing acid-base balance, they are not the primary concern when administering furosemide.

Choice C rationale

Phosphate levels are not typically affected by furosemide and are not the main focus before administration. Monitoring phosphate might be important in other scenarios, but it is not directly relevant here.

Choice D rationale

Carbon dioxide levels are more relevant to respiratory function and acid-base balance but are not directly impacted by furosemide. The focus should be on monitoring electrolytes, particularly potassium, to prevent complications from diuretic therapy.

A. Administer a laxative to cleanse the bowel before the CT scan. B. Administer the biguanide medication as scheduled. C. Advise the client to fast for 24 hours before the CT scan. D. Ensure the client is adequately hydrated before the CT scan.

Correct Answer is D

Explanation

Choice A rationale

Administering a laxative is not necessary for a CT scan of the abdomen with contrast. Laxatives are typically used for bowel preparation for procedures like colonoscopies.

Choice B rationale

Biguanide medications such as metformin should be held before and after the administration of contrast medium to prevent lactic acidosis, particularly in clients with liver disease.

Choice C rationale

Fasting for 24 hours is not required before a CT scan with contrast medium. Typically, clients are asked to fast for a few hours prior to the procedure.

Choice D rationale

Ensuring the client is adequately hydrated helps to protect kidney function and reduce the risk of contrast-induced nephropathy. Hydration is especially important for clients with a history of liver disease.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has heart failure and a new prescription for furosemide.Which of the following laboratory values should the nurse review before administering furosemide?

Correct Answer is B

Explanation

A client diagnosed with type II diabetes controlled with a biguanide medication and a history of liver disease is scheduled for a computed tomography (CT) scan with contrast medium of the abdomen to evaluate pancreatic function.Which intervention should the nurse implement?

Correct Answer is D

Explanation

What information should the nurse relay to the client with a hiatal hernia diagnosis?

A client is admitted to the emergency department with fever, chills, and severe left costovertebral pain.Which diagnostic test should be prioritized to evaluate the underlying cause of these symptoms?

To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually? Select all that apply.

The nurse is caring for a client who has heart failure and a history of asthma.The nurse reviews the provider's orders and recognizes that clarification is needed for which of the following medications?

After teaching a patient with chronic stable angina about nitroglycerin, the nurse recognizes the need for further teaching when the patient makes which statement?

A nurse is planning care for a client who is scheduled for a bronchoscopy.Which of the following interventions should the nurse include in the plan?

A 24-year-old female client comes to the ambulatory care center in moderate distress with a probable diagnosis of acute cystitis.Which symptom should the nurse expect the client to report during the assessment?

A nurse is caring for a client who has diabetic ketoacidosis and hypoxia.Which of the following interventions is most critical to perform immediately?