Four hours following surgical repair of a compound fracture of the right ulna, the nurse is unable to palpate the client’s right radial pulse. Which action should the nurse take first?

Elevate the client’s right hand on one or two pillows.

Measure the client’s blood pressure and apical heart rate.

Complete a neurovascular assessment of the right hand.

Notify the healthcare provider quickly.

Answer and Explanation

The Correct Answer is C

Choice A reason: Elevating the hand reduces edema, potentially improving circulation, but is premature without assessing the absent radial pulse’s cause. Post-fracture, compartment syndrome or arterial injury risks ischemia. Neurovascular assessment identifies severity, guiding targeted interventions to restore perfusion, making elevation secondary to assessment.

Choice B reason: Measuring blood pressure and heart rate provides systemic data but not localized insight into the absent radial pulse, likely from arterial compression post-surgery. Neurovascular assessment evaluates limb perfusion, detecting compartment syndrome or occlusion, critical for urgent intervention to prevent tissue necrosis.

Choice C reason: Completing a neurovascular assessment evaluates pulse, color, warmth, sensation, and movement. Absent radial pulse post-fracture suggests compartment syndrome or arterial injury, risking ischemia. This confirms vascular compromise, guiding interventions like fasciotomy, addressing the pathophysiological threat to limb viability, ensuring timely treatment.

Choice D reason: Notifying the provider follows assessment. Absent radial pulse suggests compartment syndrome, where swelling impairs arterial flow. Neurovascular assessment quantifies severity (e.g., pallor, paresthesia), ensuring accurate reporting for urgent intervention, preventing delays in treating vascular compromise critical to limb preservation.

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Correct Answer is B

Explanation

Choice A reason: Connecting to suction is inappropriate, as “coffee ground” drainage indicates upper GI bleeding, likely from an ulcer. Suction could worsen bleeding by traumatizing the site. Clamping and notifying the provider ensure assessment, preventing further hemorrhage or complications like perforation in this critical scenario.

Choice B reason: “Coffee ground” drainage suggests oxidized blood from upper GI bleeding (e.g., gastritis). Clamping prevents irritation or bleeding exacerbation, and contacting the provider ensures urgent evaluation, possibly via endoscopy or proton pump inhibitors, addressing the bleeding source to stabilize the client and prevent shock.

Choice C reason: Removing and reinserting the tube risks further trauma to the bleeding site, as “coffee ground” drainage indicates active hemorrhage. Repeated insertion may dislodge clots, worsening bleeding. Clamping and notifying the provider prioritize safety, allowing diagnostic and therapeutic interventions for the underlying cause.

Choice D reason: High continuous suction is contraindicated, as “coffee ground” drainage signals GI bleeding, and aggressive suction could dislodge clots, increasing hemorrhage. Clamping and contacting the provider ensure controlled management, preventing complications like hypovolemic shock, making this action harmful and inappropriate.

A. Administer a PRN narcotic. B. Ask the husband to step out. C. Have delivery table set up. D. Notify rapid response team.

Correct Answer is C

Explanation

Choice A reason: Administering a PRN narcotic at 9 cm dilation is inappropriate, as labor is in transition, nearing delivery. Narcotics risk fetal respiratory depression, crossing the placenta, especially with a stable fetal heart rate (120 beats/minute). Preparing for imminent delivery is critical, prioritizing a safe birth environment over pain relief.

Choice B reason: Asking the husband to leave does not address the client’s advanced labor (9 cm, 100% effaced, frequent contractions). His presence may provide support, and removal could increase distress. Setting up the delivery table is urgent, as birth is imminent, ensuring a sterile, safe environment for delivery.

Choice C reason: At 9 cm dilation, 100% effacement, and contractions every 2 minutes, the client is in transition, with delivery imminent. Setting up the delivery table ensures readiness for vaginal birth, providing a sterile field and equipment, addressing the physiological progression of labor for safe delivery of the newborn.

Choice D reason: Notifying the rapid response team is unnecessary, as the fetal heart rate (120 beats/minute) is normal (110–160), and screaming reflects labor pain. Delivery is imminent, making table setup the priority to facilitate safe birth, avoiding escalation to emergency response for a normal labor progression.

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Four hours following surgical repair of a compound fracture of the right ulna, the nurse is unable to palpate the client’s right radial pulse. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has a prescription for the insertion of a nasogastric tube to low intermittent suction. When inserting the nasogastric tube, the nurse observes an immediate return of “coffee ground” drainage. Which action should the nurse implement?

Correct Answer is B

Explanation

A primigravida at 40 weeks gestation is contracting every 2 minutes, and her cervix is 9 cm dilated and 100% effaced. The fetal heart rate is 120 beats/minute. The client is screaming and her husband is alarmed. Which intervention should the nurse implement?

Correct Answer is C

Explanation

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