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 A

Explanation

Choice A rationale

The inability to locate a dorsalis pedis pulse and increasing pain indicate compromised circulation, which requires immediate attention to prevent complications.

Choice B rationale

Pain relieved after administering medication indicates effective pain management, which is not an urgent issue to report immediately.

Choice C rationale

Generalized weakness and increasing sensitivity to touch can be concerning but are not as urgent as signs of compromised circulation.

Choice D rationale

Localized edema and discoloration are expected findings in a fracture and are not as urgent as an absent pulse. .

A. Administering post-procedure antibiotics to prevent infection. B. Providing pre-procedure sedation as ordered. C. Ensuring the client is NPO (nothing by mouth) for a specific period of time before the procedure. D. Encouraging the client to drink plenty of fluids before the procedure.

Correct Answer is C

Explanation

Choice A rationale

Administering post-procedure antibiotics is not typically required for a bronchoscopy unless there is evidence of infection. The procedure itself does not inherently pose a high risk of infection requiring antibiotics as a preventative measure.

Choice B rationale

Providing pre-procedure sedation is important to ensure the client is comfortable and relaxed during the bronchoscopy. This helps minimize discomfort and anxiety associated with the procedure.

Choice C rationale

Ensuring the client is NPO (nothing by mouth) for a specific period before the procedure is crucial to prevent aspiration. Aspiration can occur if the client has food or liquid in their stomach, posing a serious risk during the insertion of the bronchoscope.

Choice D rationale

Encouraging the client to drink plenty of fluids before the procedure is not appropriate because the client needs to be NPO to prevent aspiration risks during the bronchoscopy.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client diagnosed with a fractured tibia and fibula.Which data should the nurse report to the healthcare provider immediately?

Correct Answer is A

Explanation

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?

Correct Answer is C

Explanation

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.

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 client is admitted to the emergency room with chest pain and a suspected diagnosis of acute myocardial infarction (MI). Which test would the nurse expect the physician to order to make a definitive diagnosis of MI?

The nurse is preparing to administer sodium polystyrene sulfonate (Kayexalate) rectally to a patient with an irregular pulse and weakness of the lower extremities.What laboratory finding does the nurse determine is the reason for this treatment?

Which of the following is a rationale for prescribing total parenteral nutrition (TPN) for a patient with inflammatory bowel disease (IBD)?

The nurse is caring for a client diagnosed with a fractured tibia and fibula.Which data should the nurse report to the healthcare provider immediately?

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?

A client was seen in the emergency room with a complaint of severe episodes of vomiting and diarrhea, and complains of feeling lightheaded.Which laboratory test should the nurse prioritize?