An intubated 30-year-old is being treated in the critical care unit after coming into contact with a high voltage power line. The client’s left leg received a compound fracture as well as a full thickness circular burn. Three days post-injury a fasciotomy was performed. Which assessment findings indicate effectiveness of the actions taken by the nurse? (Select all that apply)

Pedal pulse 88 beats/min, bilaterally.

No swelling noted in lower extremities.

Spontaneous respirations, 16 breaths/minute.

Pulse oximeter reading 93%.

Pain scored 5 out of 10, decreased from high of 10.

Temperature 98.6°F.

Answer and Explanation

Correct Answer : A,B,E

Choice A reason: Bilateral pedal pulses at 88 beats/min indicate restored circulation post-fasciotomy, preventing compartment syndrome. This aligns with vascular assessment post-burn and fracture, making it a correct finding showing the nurse’s actions were effective in maintaining perfusion in the leg.

Choice B reason: No swelling in lower extremities post-fasciotomy indicates reduced pressure and effective decompression, preventing tissue damage. This aligns with post-surgical burn care, making it a correct finding demonstrating the nurse’s actions were successful in managing the client’s leg injury.

Choice C reason: Spontaneous respirations are expected with intubation but unrelated to fasciotomy effectiveness for leg burn and fracture. Pulse presence is more relevant, making this incorrect, as it does not reflect the outcome of the nurse’s actions on the leg injury.

Choice D reason: Pulse oximetry of 93% reflects respiratory status, not fasciotomy effectiveness for leg perfusion. No swelling is a direct outcome, making this incorrect, as it’s unrelated to the nurse’s actions addressing the burn and fracture in the client’s leg.

Choice E reason: Pain reduced to 5/10 from 10 post-fasciotomy indicates effective decompression and pain management. This aligns with post-surgical burn care outcomes, making it a correct finding showing the nurse’s actions improved the client’s comfort and leg injury status.

Choice F reason: Normal temperature of 98.6°F is expected but doesn’t directly indicate fasciotomy effectiveness for leg perfusion. Pedal pulses are more specific, making this incorrect, as it’s not a primary outcome of the nurse’s actions for the client’s leg injury.

Nursing Test Bank

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Correct Answer is A

Explanation

Choice A reason: Malodorous flatus 2 days post-colostomy is normal, indicating bowel function resumption. This aligns with postoperative colostomy expectations, making it the correct interpretation by the nurse, as flatus is an expected milestone in the client’s recovery process.

Choice B reason: Ischemic bowel causes pain, fever, or absent output, not just malodorous flatus, which is normal post-colostomy. This is incorrect, as it misinterprets a typical finding as a serious complication in the nurse’s assessment of the client’s stoma.

Choice C reason: Flatus doesn’t indicate the need for a nasogastric tube, which is used for obstruction or ileus. Normal flatus is expected, making this incorrect, as it wrongly suggests intervention for a typical post-colostomy finding in the nurse’s evaluation.

Choice D reason: Malodorous flatus is unrelated to preoperative bowel preparation; it’s a normal post-colostomy event. This is incorrect, as it misattributes a standard recovery sign to surgical preparation, unlike the nurse’s correct interpretation of expected bowel function.

A. The patient will continue to receive the same aggressive treatment short of resuscitation if he has another cardiac arrest. B. All treatment will be stopped, and the patient will be allowed to die. C. All attempts will be made to keep the patient comfortable without prolonging his life. D. The patient will be immediately transferred to hospice.

Correct Answer is C

Explanation

Choice A reason: Aggressive treatment continues curative care, not palliative care, which focuses on comfort. A DNR prioritizes comfort, making this incorrect, as it contradicts the nurse’s understanding of palliative care’s role in the patient’s treatment plan post-DNR.

Choice B reason: Stopping all treatment isn’t palliative care, which includes comfort measures like pain relief. Comfort without prolonging life is correct, making this incorrect, as it misrepresents the nurse’s expectation of continued supportive care under a DNR order.

Choice C reason: Palliative care with a DNR focuses on comfort, such as pain management, without prolonging life. This aligns with end-of-life care principles, making it the correct description of how the DNR and palliative care affect the patient’s treatment plan.

Choice D reason: Hospice transfer may occur later, but palliative care can begin in the hospital. Comfort care is immediate, making this incorrect, as it’s not the primary effect of the DNR compared to the nurse’s focus on current palliative treatment.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

A nurse is providing teaching to a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates an understanding of the teaching?

The nurse cares for a client in the emergency department diagnosed with deep partial thickness burns of the arms and chest. The nurse notes that the client is very restless and anxious. Which action should the nurse take FIRST?

Which client will the nurse recognize as having the greatest risk for development of hypocalcemia?

The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? (Select all that apply)

The nurse in the emergency department (ED) is assessing a client with anaphylactic shock. Which of the following findings would support a diagnosis of anaphylactic shock? (Select all that apply)

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations supports this diagnosis? (Select all that apply)

A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? (Select all that apply)

The nurse caring for a client with chronic obstructive pulmonary disease (COPD) anticipates which arterial blood gas (ABG) findings?