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.
Correct Answer : A,B,D
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E","F","G"]
Explanation
Based on the provided information, the following aspects of the assessment require urgent attention:
- The client’s request for sleeping medication: This indicates that she is having trouble sleeping, which can affect her recovery.
- The client’s distressing thoughts and memories about the house collapsing: This could be a sign of post-traumatic stress disorder (PTSD), which requires immediate attention and possibly referral to a mental health professional.
- The client’s statement about being in a “funk”: This could indicate depression or another mental health issue, which should be addressed promptly.
- The client’s preference for a quieter area of the unit: The noise by the nurses’ station is disturbing her rest, which is crucial for her recovery. Efforts should be made to accommodate her request if possible.
Correct Answer is C
Explanation
Choice A rationale
Responding to the code while performing tracheostomy care could potentially put the current patient at risk. The nurse has a responsibility to ensure the safety of the patient they are currently caring for.
Choice B rationale
Closing the room door does not address the immediate needs of either patient and does not contribute to the safety or care of the patients.
Choice C rationale
Calling for an assistant is the most appropriate action. This allows the nurse to ensure the safety of the current patient while also allowing for a response to the code blue. The assistant can continue care for the current patient, or the nurse can delegate the assistant to respond to the code while the nurse continues care for the current patient.
Choice D rationale
Finishing the procedure could delay response to the code blue, potentially putting the other patient at risk.
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