As a nurse, you are reviewing the orders and planning initial steps for caring for the same patient.
Which interventions should you perform?

Check capillary refill on bilateral upper extremities.

Administer morphine 2 mg IV as ordered.

Perform range of motion exercises.

Administer ondansetron 4 mg IV as ordered.

Answer and Explanation

Correct Answer : A,B,D

Choice A rationale

Checking capillary refill on bilateral upper extremities can help assess peripheral circulation and identify any potential vascular injuries.

Choice B rationale

Administering morphine 2 mg IV as ordered would help manage the patient’s pain.

Choice C rationale

Performing range of motion exercises may not be appropriate immediately after the fall and before the extent of the patient’s injuries are fully assessed.

Choice D rationale

Administering ondansetron 4 mg IV as ordered can help manage any nausea or vomiting that the patient may experience, which can be a side effect of the morphine or a result of the fall itself. TemazepamTemazepam Explore

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Correct Answer is ["A","B","C","D","F"]

Explanation

A.Bone misalignment- The nurse’s notes mention that the collarbone appears out of alignment on the left side. This could indicate a fracture or dislocation and should be investigated further.

B.Decreased range of motion- The client reports an inability to move his left arm. This could be due to the pain or a result of the injury and should be investigated further.

C.Left arm that is cool to touch- Decreased temperature in a limb can indicate poor circulation, which could be a result of the injury. This should be investigated further.

D.Swelling at the site of injury- Swelling and bruising are present on the client’s shoulder. This is a common sign of injury and should be investigated further.

E.Blood pressure of 136/90 mm Hg- While this blood pressure is not extremely high, it is on the higher end of normal. Given the client’s age and the stress of the situation, it would be worth monitoring.

F.Intense pain reported by client- The client reports a pain rating of 10 on a 0 to 10 scale in the left arm. This level of pain is concerning and should be addressed.

G.Oxygen saturation 95% on room air- While an oxygen saturation of 95% is within the normal range, given the client’s recent trauma and reported nausea, it would be prudent to monitor this closely.

A. Diarrhea and flatulence. B. Abdominal cramps. C. Altered taste. D. Muscle pain.

Correct Answer is D

Explanation

Choice A rationale

Diarrhea and flatulence are common side effects of lovastatin, but they are not typically serious enough to require immediate follow-up.

Choice B rationale

Abdominal cramps can occur with lovastatin use, but they are not usually a sign of a serious problem.

Choice C rationale

Altered taste is a less common side effect of lovastatin and is not typically a cause for immediate concern.

Choice D rationale

Muscle pain can be a sign of a rare but serious side effect of lovastatin called rhabdomyolysis. This condition involves the breakdown of muscle tissue, which can lead to kidney damage. Therefore, this symptom should be prioritized for immediate follow-up.

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As a nurse, you are reviewing the orders and planning initial steps for caring for the same patient.Which interventions should you perform?

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Naxlex Comprehensive Predictor Exams

Exhibits The nurse considers the brief interaction with the client and the triage report. What finding(s) should the nurse investigate further? Select all that apply.

Correct Answer is ["A","B","C","D","F"]

Explanation

Which of the following symptoms reported by a patient taking lovastatin should the nurse prioritize for immediate follow-up?

Correct Answer is D

Explanation

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As a nurse, you are reviewing the orders and planning initial steps for caring for the same patient.
Which interventions should you perform?