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.

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Free Nursing Study Resources

Correct Answer is ["A","B","E","G","H"]

Explanation

Choice A reason: Tea, especially caffeinated, relaxes the lower esophageal sphincter, worsening GERD symptoms. Avoiding it shows understanding, making this a correct food the nurse would expect the client to avoid based on dietary education to prevent GERD exacerbation.

Choice B reason: Beer, an alcoholic beverage, irritates the esophagus and relaxes the sphincter, triggering GERD symptoms. Avoiding it reflects correct understanding, making this a correct food the nurse would include in teaching for the client to prevent GERD flare-ups.

Choice C reason: Cheese, while high-fat, is less likely to trigger GERD than alcohol or chocolate. Oatmeal is GERD-friendly, making this incorrect, as it’s not a primary trigger compared to the nurse’s teaching on foods to avoid for GERD symptom management.

Choice D reason: Oatmeal is a bland, high-fiber food that soothes GERD symptoms, not exacerbating them. Avoiding chocolate is correct, making this incorrect, as it’s a beneficial food, unlike the triggers the nurse teaches the client to avoid in GERD management.

Choice E reason: Chocolate contains caffeine and fat, relaxing the esophageal sphincter and worsening GERD. Avoiding it shows understanding, making this a correct food the nurse would expect the client to avoid to prevent symptom exacerbation based on GERD dietary teaching.

Choice F reason: Sweet potatoes are low-fat and non-irritating, not triggering GERD symptoms. Avoiding alcohol is correct, making this incorrect, as it’s a safe food, unlike the nurse’s teaching on foods the client should avoid to manage GERD effectively.

Choice G reason: Alcohol, including beer, relaxes the esophageal sphincter and irritates the mucosa, exacerbating GERD. Avoiding it reflects understanding, making this a correct food the nurse would include in teaching for the client to prevent GERD symptom flare-ups.

Choice H reason: French fries, high in fat, delay gastric emptying and worsen GERD symptoms. Avoiding them shows understanding, making this a correct food the nurse would expect the client to avoid based on dietary education to manage GERD effectively.

A. Administer furosemide (Lasix) 40 mg IV. B. Decrease the rate of the IV fluids and notify the health care provider. C. Document the CVP reading in the chart. D. Check the client’s urine specific gravity.

Correct Answer is B

Explanation

Choice A reason: Administering furosemide without a provider’s order is outside nursing scope and risks harm. Decreasing IV fluids addresses elevated CVP, making this incorrect, as it bypasses protocol compared to the nurse’s priority of adjusting fluids and consulting the provider.

Choice B reason: A CVP of 16 cm H2O suggests fluid overload; decreasing IV fluids and notifying the provider prevents worsening heart failure. This aligns with hemodynamic monitoring protocols, making it the correct action for the nurse to take to address the client’s elevated CVP.

Choice C reason: Documenting the CVP is necessary but doesn’t address the urgent fluid overload indicated by 16 cm H2O. Decreasing fluids is proactive, making this incorrect, as it delays intervention compared to the nurse’s priority of managing the client’s high CVP.

Choice D reason: Checking urine specific gravity assesses hydration but is less urgent than addressing elevated CVP with fluid adjustment. Notifying the provider takes precedence, making this incorrect, as it’s secondary to the nurse’s action to manage fluid overload immediately.

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Naxlex Comprehensive Predictor Exams

The nurse is providing dietary education to a client with gastroesophageal reflux disease (GERD). The nurse indicates that the client understands the teaching if the client states a plan to avoid which foods to prevent symptom exacerbation? (Select all that apply)

Correct Answer is ["A","B","E","G","H"]

Explanation

The nurse cares for a client with 0.9% sodium chloride infusing at 125 mL/h. 2 hours after the infusion was started, the client’s central venous pressure (CVP) reading is 16 cm H2O. It is MOST important for the nurse to take which action?

Correct Answer is B

Explanation

You are working on a busy unit and need to delegate tasks to the LPN and M

Which assessments are most important for the nurse to perform to prevent harm on a client with a sodium level of 118 mEq/L (mmol/L)? (Select all that apply)

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 is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items would the nurse include on this list? (Select all that apply)

The nurse notes that a client’s T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate?

The nurse is providing care for a client with a bowel obstruction who had a transverse colostomy created. Which observation requires immediate notification of the primary health care provider?

In collaboration with the registered dietitian nutritionist (RDN), which foods will the nurse teach a client who is taking a potassium-sparing diuretic to avoid or use cautiously? (Select all that apply)