Exhibits
The nurse reviews the orders and plans initial steps for caring for the client.
Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.
Inspect the bandage for drainage
Perform range of motion.
Administer ondansetron 4 mg IV.
Provide morphine 2 mg IV.
Check capillary refill on bilateral upper extremities
Palpate and compare radial pulses.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}
Inspect the bandage for drainage: This is a standard post-injury assessment to monitor for excessive bleeding or other complications.
Perform range of motion: Range of motion exercises are contraindicated in cases of fractures, as movement could worsen the injury.
Administer ondansetron 4 mg IV: Ondansetron is an antiemetic that can help relieve the nausea the client is experiencing.
Provide morphine 2 mg IV: Morphine is indicated for pain management, especially since the client is experiencing significant pain.
Check capillary refill on bilateral upper extremities: This is important to assess circulation and ensure there is no vascular compromise.
Palpate and compare radial pulses: This assesses circulation and can help identify any vascular injury or compromise due to the humeral fracture.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Anorexia Nervosa
The client's symptoms, such as low body weight (BMI of 16.8 kg/m²), bradycardia (HR of 48 bpm), hypothermia (temperature of 96.2°F), poor muscle tone, irregular menstruation, and the presence of lanugo, all strongly suggest anorexia nervosa. Additionally, the client's refusal to acknowledge weight loss and her distorted perception of body image further support this diagnosis.
Actions the Nurse Should Take:
Educate on the condition:
The nurse should educate the client and her family about the physical and psychological aspects of anorexia nervosa, including the risks of severe malnutrition, electrolyte imbalances, and long-term complications if not treated.
Acknowledge anxious feelings:
The nurse should validate the client’s anxious feelings about food and body image, providing emotional support and promoting a therapeutic relationship to encourage the client to engage in treatment.
Parameters to Monitor:
Weight:
Monitoring the client’s weight regularly is essential to assess nutritional progress and to detect any further weight loss or gains.
Achievement of 100% of ideal weight:
Assessing whether the client is progressing toward achieving a healthy weight (100% of ideal body weight) is a critical marker of recovery from anorexia nervosa.
Correct Answer is A
Explanation
A. Notifying the healthcare provider of abdominal pain is important, as exenatide can cause gastrointestinal side effects that may require medical evaluation.
B. This statement is misleading; exenatide does have interactions with other medications that need to be monitored.
C. Exenatide should be injected within 60 minutes before meals, not 30 minutes before or after.
D. While exenatide lowers blood glucose, it does so differently than insulin, as it also promotes insulin secretion and slows gastric emptying.
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