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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Correct Answer is A

Explanation

Choice A reason: Increasing fiber during Crohn’s exacerbation worsens diarrhea and inflammation, indicating a misunderstanding. A low-fiber diet is recommended, making this the correct statement needing further instruction, as it contradicts the nurse’s teaching on managing dietary needs during Crohn’s disease flare-ups.

Choice B reason: Avoiding caffeinated beverages is correct, as they stimulate the gut and worsen Crohn’s symptoms. This aligns with dietary teaching, making it incorrect, as it shows understanding, unlike the incorrect fiber statement requiring further instruction from the nurse.

Choice C reason: Learning stress-reduction techniques is appropriate, as stress can trigger Crohn’s exacerbations. This reflects understanding of self-management, making it incorrect, as it aligns with the nurse’s teaching, unlike the fiber statement indicating a need for further dietary instruction.

Choice D reason: Recognizing exacerbations and remissions is accurate for Crohn’s disease, showing disease knowledge. This aligns with the nurse’s education, making it incorrect, as it demonstrates understanding, unlike the fiber statement that requires further instruction to correct the client’s misconception.

A. Provide two manual breaths with a bag and mask. B. Assess the client’s pulse. C. Immediately resume chest compressions. D. Administer 1 mL of IV epinephrine.

Correct Answer is C

Explanation

Choice A reason: Providing breaths follows compressions in ACLS after defibrillation for pulseless ventricular tachycardia. Resuming compressions is immediate, making this incorrect, as it delays the nurse’s priority to restore circulation post-shock in the client’s code situation.

Choice B reason: Assessing the pulse occurs after 2 minutes of compressions, not immediately post-defibrillation. Resuming compressions is the priority, making this incorrect, as it’s premature compared to the nurse’s focus on continuing CPR in pulseless ventricular tachycardia.

Choice C reason: Resuming chest compressions immediately after defibrillation maintains circulation in pulseless ventricular tachycardia per ACLS guidelines. This aligns with code management, making it the correct next step for the nurse to perform to optimize the client’s resuscitation efforts.

Choice D reason: Epinephrine is given after the second shock or per protocol, not immediately post-defibrillation. Compressions are the priority, making this incorrect, as it’s not the next step in the nurse’s ACLS sequence for managing the client’s arrhythmia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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 client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse would assess the client during dialysis for which associated manifestations?

The nurse is reviewing a client’s record and notes that the primary health care provider has documented that the client has chronic kidney disease. On review of the laboratory results, the nurse most likely would expect to note which finding?

A client with severe ulcer disease in the distal stomach undergoes a gastrojejunostomy (Billroth II procedure). Which postoperative prescription would the nurse question and verify?

You are taking care of 4 clients who are receiving opioid analgesics for pain management. Which patient is MOST likely to be experiencing a life-threatening opioid side effect?