Exhibits

The nurse reviews the prescriptions 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.

Palpate and compare radial pulses.

Administer ondansetron 4 mg IV.

Perform range of motion.

Check capillary refill on bilateral upper extremities.

Inspect the bandage for drainage.

Provide morphine 2 mg IV push (IVP).

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Rationale:

Palpate and compare radial pulses: It is important to check radial pulses to assess circulation to the injured limb. Decreased pulse strength, especially in the left arm, could indicate vascular injury, which requires immediate attention.
Administer ondansetron 4 mg IV: The client is feeling nauseated and worries about vomiting, likely due to postoperative effects, pain medication, or anesthesia. Ondansetron is an antiemetic, which is appropriate to administer to manage nausea and prevent vomiting.
Check capillary refill on bilateral upper extremities: Checking capillary refill is essential to assess perfusion to both arms. The client’s left arm is experiencing coolness, and diminished pulses were noted earlier, so this is necessary to monitor blood flow and prevent complications like compartment syndrome.
Inspect the bandage for drainage: After surgery, it is important to inspect the surgical site for any drainage, bleeding, or signs of infection. This helps ensure that there are no complications or issues with wound healing.

Perform range of motion: Performing range of motion exercises is contraindicated immediately after trauma, especially with a fracture or suspected injury to the shoulder. The shoulder should be immobilized to prevent further damage and to facilitate proper healing. Early movement may worsen the injury or cause additional pain.
Provide morphine 2 mg IV push (IVP): While he had a nerve block, its effectiveness will wane, and he will likely experience significant pain from the fracture and surgical manipulation. Administering prescribed analgesia like morphine is a priority for pain management.

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Correct Answer is B

Explanation

A. The woman is timid and speaks softly when asked about the accident: Timid behavior may suggest fear or anxiety, but it's nonspecific and may be due to trauma or emotional distress, not necessarily abuse.

B. Spiral fracture on the woman's arm and wrist: Spiral fractures occur from twisting injuries and are often associated with non-accidental trauma, especially when the injury doesn't match the reported mechanism.

C. The woman is hyperventilating and appears to be in pain: Hyperventilation and visible pain may indicate anxiety or physical injury, but they are expected after trauma and not unique to domestic violence.

D. Fresh bruises on the woman's shoulder and chest: Bruising is a possible sign of abuse, but bruises alone can result from a car accident. The type and location must be assessed in context.

A. Provide handouts written at a 12th grade reading level. B. Use background music to promote relaxation. C. Turn on overhead lights while giving instructions. D. Stand behind the client to avoid intimidation.

Correct Answer is C

Explanation

A. Provide handouts written at a 12th grade reading level: Educational materials should be written at an appropriate reading level for the client, typically 6th to 8th grade for older adults, to promote understanding. Handouts at a 12th-grade level might be too complex.

B. Use background music to promote relaxation: While this could potentially help reduce anxiety for some people, it may also be distracting for others during important health teaching. The priority is clear and focused communication.

C. Turn on overhead lights while giving instructions: Proper lighting is essential, especially for older adults who may have visual impairments. Bright, direct lighting can help ensure the client clearly sees instructional materials and feels more comfortable during teaching.

D. Stand behind the client to avoid intimidation: Standing behind the client can be intimidating and might make the interaction feel less personal. It's important to engage the client in a way that encourages open communication, typically by sitting or standing at eye level.

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Exhibits The nurse reviews the prescriptions 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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A woman and her live-in significant other come in the emergency department following a motor vehicle collision. Which finding should alert the nurse to assess for the possibility of domestic violence?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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Exhibits

The nurse reviews the prescriptions 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.