Exhibits
Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.
Check capillary refill on bilateral upper extremities.
Administer ondansetron 4 mg IV.
Inspect the bandage for drainage.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"}}
Based on the provided information, here are the interventions the nurse should perform:
- Check capillary refill on bilateral upper extremities. - Indicated: This is important to assess the client’s circulation, especially given the coolness of the left arm and the fracture in the left shoulder.
- Administer ondansetron 4 mg IV. - Contraindicated: There is no prescription for ondansetron and no indication of nausea or vomiting from the client.
- Inspect the bandage for drainage. - Indicated: Given the client’s recent surgery and the presence of swelling and bruising, it’s important to monitor for any signs of infection or complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Encouraging the client to drink at least 3 to 4 liters of water prior to the procedure is not a standard preparation for an intravenous pyelogram (IVP). Overhydration could potentially complicate the procedure.
Choice B rationale
It is essential for the nurse to notify the healthcare provider if the client reports any allergies to iodine or shellfish. The contrast dye used in an IVP often contains iodine. People who are allergic to iodine or shellfish may have a reaction to this dye.
Choice C rationale
Instructing the client to keep the legs straight for 6 to 8 hours after the procedure is not a standard instruction for IVP. This instruction is more commonly associated with procedures involving the insertion of a catheter into a large artery or vein.
Choice D rationale
Inserting an indwelling urinary catheter prior to going to the X-ray department is not a standard preparation for an IVP. The procedure involves the injection of a contrast dye into a vein, not the bladder.
Correct Answer is A
Explanation
Choice A rationale
Instructing the patient that it is important to reduce the dose of the medication gradually is the best course of action. Temazepam is a benzodiazepine, and abrupt discontinuation can lead to withdrawal symptoms, which can be severe and include seizures. Therefore, it’s crucial to taper off the medication under the supervision of a healthcare provider.
Choice B rationale
Advising the patient to stop taking the medication immediately is not recommended due to the risk of withdrawal symptoms.
Choice C rationale
Encouraging the patient to obtain a prescription for a benzodiazepine antagonist is not typically the first line of action when discontinuing temazepam.
Choice D rationale
Discussing with the patient that there may be a need for additional sleep if the feeling of fatigue is present the next day is not directly addressing the issue. The patient’s feelings of being “hungover” are likely due to the effects of the medication, not a lack of sleep.
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