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: Inserting a small bore tube for enteral feedings is inappropriate for acute GERD exacerbation, as feeding increases gastric volume, worsening reflux by raising pressure and acid exposure. Proton pump inhibitors (PPIs) reduce acid production, alleviating mucosal irritation, addressing GERD’s pathophysiology more effectively than nutritional interventions.

Choice B reason: Intravenous PPIs (e.g., pantoprazole) are standard for severe GERD, inhibiting H+/K+-ATPase in parietal cells, reducing acid secretion. This promotes esophageal healing when oral famotidine fails. IV delivery ensures rapid onset, critical for controlling worsening symptoms, preventing complications like esophagitis or Barrett’s esophagus in acute settings.

Choice C reason: Total parenteral nutrition (TPN) bypasses the gut, used for conditions like bowel obstruction, not GERD, which involves acid reflux from sphincter dysfunction. TPN does not address acid production. PPIs target the pathophysiological cause, reducing esophageal acid exposure, making TPN irrelevant for GERD management.

Choice D reason: A nasogastric tube with suction removes gastric contents but does not treat GERD’s acid reflux, caused by lower esophageal sphincter dysfunction. It risks aspiration and is temporary. PPIs effectively reduce acid, preventing esophageal damage, making them the preferred treatment for severe GERD exacerbation.

A. Reports difficulties with short-term memory since a traumatic brain injury. B. Describes self as a social drinker who drinks alcoholic beverages daily. C. Client’s medication history includes the frequent use of antidepressants. D. Medical history includes that the client was recently sexually assaulted.

Correct Answer is B

Explanation

Choice A reason: Memory issues from TBI traumatic brain injury warrant cognitive assessment, not CAGE, which screens for alcoholism. Daily drinking suggests potential misuse, requiring CAGE. Memory affects recall, not alcohol screening priority, per substance abuse and neurological assessment standards in nursing admission interviews.

Choice B reason: Daily social drinking raises suspicion for alcohol misuse, warranting the CAGE questionnaire to screen for dependence. CAGE assesses alcohol-related behaviors, critical for identifying alcoholism in clients with regular intake, per substance abuse screening and admission assessment protocols in nursing practice.

Choice C reason: Antidepressant medication use suggests depression, requiring mental health assessment, not CAGE, which is for alcohol misuse. Daily drinking indicates screening need. Antidepressants are unrelated to alcohol patterns, per psychiatric and substance abuse assessment standards in nursing care during admission.

Choice D reason: Sexual assault history trauma requires trauma-informed care, not CAGE, which screens for alcoholism. Daily drinking triggers alcohol misuse screening. Assault history addresses psychological needs, per trauma assessment and substance abuse screening protocols, but CAGE is specific to alcohol in nursing.

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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

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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