An adolescent client with non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. The healthcare provider collects bone aspirate specimens for culture and sensitivity and applies a cast to the adolescent's lower leg. Which action should the nurse implement next?

Begin parenteral antibiotic therapy.

Administer antiemetic agents.

Provide a high-calorie, high-protein diet.

Bivalve the cast for distal compromise.

Answer and Explanation

The Correct Answer is A

A. Begin parenteral antibiotic therapy.
This is the correct answer. Osteomyelitis is a serious bone infection that requires prompt and aggressive antibiotic therapy to prevent further complications and promote healing.

B. Administer antiemetic agents.
Antiemetic agents may be necessary if the client is experiencing nausea or vomiting, but this is not the priority action.

C. Provide a high-calorie, high-protein diet.
While nutritional support is important for healing, initiating antibiotic therapy to address the infection takes precedence.

D. Bivalve the cast for distal compromise.
Bivalving the cast might be necessary if there is evidence of compartment syndrome or impaired circulation, but there is no indication from the question that such a complication is present at this time.

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Correct Answer is A

Explanation

A. Test the fluid on the dressing for glucose.
This is the correct action. Clear fluid on a dressing after lumbar spinal surgery could indicate a cerebrospinal fluid (CSF) leak. Testing the fluid for glucose is essential because CSF contains glucose, whereas normal wound drainage does not. A positive glucose test would confirm the presence of CSF, indicating a potential complication that requires immediate medical attention.

B. Mark the drainage area with a pen and continue to monitor.
While monitoring the size of the drainage area can be useful, it is not the immediate priority. The nurse should first determine whether the clear fluid is CSF.

C. Change the dressing using a compression bandage.
Changing the dressing might be necessary, but using a compression bandage without first identifying the nature of the fluid could be inappropriate and potentially harmful if the fluid is CSF.

D. Document the findings in the electronic medical record.
Documentation is important, but it is not the immediate action. The nurse needs to identify the nature of the fluid first.

A. Maintain nasal packing. B. Keep head of bed at 30°. C. Provide frequent mouth care. D. Monitor Intake and output.

Correct Answer is C

Explanation

A. Maintaining nasal packing may be important post-hypophysectomy to prevent bleeding or cerebrospinal fluid leaks. However, in the context of Cushing's disease, ensuring oral hygiene is
paramount due to increased risk of infection, especially if the patient is on corticosteroid therapy, which suppresses the immune system.

B. Keeping the head of the bed at 30° helps prevent complications such as cerebral edema and increased intracranial pressure. While this is important post-hypophysectomy, it's not specific to Cushing's disease or a priority over oral care.

C. Providing frequent mouth care is crucial in Cushing's disease due to increased cortisol levels leading to immunosuppression and susceptibility to infections. Additionally, glucocorticoid therapy can cause mucosal dryness and ulceration, necessitating meticulous oral hygiene.

D. Monitoring intake and output is essential postoperatively to assess fluid balance and renal function. While important, it's not the priority in this context compared to oral care, especially considering the risk of dehydration due to increased cortisol levels in Cushing's disease.

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An adolescent client with non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. The healthcare provider collects bone aspirate specimens for culture and sensitivity and applies a cast to the adolescent's lower leg. Which action should the nurse implement next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. Which action should the nurse implement immediately?

Correct Answer is A

Explanation

The nurse is monitoring a client with Cushing's disease in the postanesthesia care unit (PACU) after a hypophysectomy. Which intervention is most important for the nurse to include in the client's plan of care?

Correct Answer is C

Explanation

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