Patient Data
Click to highlight the findings that would indicate the client is progressing as expected.
The nurse assesses the client. The client reports he was able to sleep through the night. The client notes continued numbness in his left arm, along with a tingling sensation, and is not able to move his fingers. The client reports mild nausea and has no desire to eat breakfast. There is a 1.18 in (3 cm) by 1.97 in (5 cm) area of blood noted on the bandage. The left arm is warm to touch. The client's left shoulder and collarbone are symmetric.
The client reports he was able to sleep through the night
continued numbness in his left arm, along with a tingling sensation, and is not able to move his fingers
The client reports mild nausea and has no desire to eat breakfast
There is a 1.18 in (3 cm) by 1.97 in (5 cm) area of blood noted on the bandage
The left arm is warm to touch
The client's left shoulder and collarbone are symmetric.
The Correct Answer is ["A","E","F"]
Rationale for Correct Choices:
- The client reports he was able to sleep through the night: Adequate rest indicates improved comfort and effective pain management postoperatively.
- The left arm is warm to touch: Warmth confirms adequate circulation and tissue perfusion following surgery.
- The client's left shoulder and collarbone are symmetric: Symmetry suggests proper surgical alignment and absence of acute displacement or swelling.
Rationale for Incorrect Choices:
- Continued numbness in the left arm, tingling, and inability to move fingers: These findings raise concern for possible neurovascular compromise or prolonged effects of the nerve block.
- Mild nausea and lack of desire to eat breakfast: This can be a transient side effect of anesthesia or analgesics but requires monitoring for persistence.
- A 3 cm × 5 cm area of blood noted on the bandage: Postoperative dressings should have minimal drainage, so this amount of blood warrants assessment for active bleeding or hematoma formation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A,B"},"E":{"answers":"A"}}
Explanation
Reduced pulse distal to injury: A humeral fracture can damage surrounding vasculature, especially the brachial artery, leading to compromised circulation. This results in weak or absent distal pulses, which requires urgent evaluation for possible neurovascular compromise.
• Decreased range of motion: Both rotator cuff injury and humeral fracture commonly cause impaired shoulder mobility. A rotator cuff tear limits abduction and overhead activities, while a fracture mechanically restricts movement due to pain, swelling, or bone displacement.
• Coolness of skin: A humeral fracture can impair blood flow by compressing or injuring vessels, producing ischemic changes such as cool skin. This finding signals inadequate perfusion, which can progress to serious complications if untreated.
• Pain with movement: Both a rotator cuff tear and humeral fracture are associated with pain on movement. In a tear, the pain stems from tendon injury and inflammation, while in a fracture, bone disruption and soft tissue trauma intensify pain when the joint is moved.
• 1+ strength in left upper extremity: Weakness in the affected arm is more typical of rotator cuff injury, as tendon disruption limits muscular function and reduces lifting ability. This differs from fracture-related pain, where strength may be preserved but restricted by pain.
Correct Answer is D
Explanation
A. Iodine: An iodine allergy is more relevant for clients receiving contrast media or iodine-based antiseptics, not dorzolamide. Dorzolamide is a carbonic anhydrase inhibitor, and its risk profile is not associated with iodine sensitivity.
B. Latex: Latex allergy is an important consideration in nursing care, particularly regarding equipment and supply use. However, dorzolamide as an ophthalmic preparation does not contain latex, so this allergy does not directly influence the safety of administering the drug.
C. Penicillin: Penicillin allergy is significant for antibiotics, but dorzolamide is not a beta-lactam or related medication. There is no cross-reactivity between penicillin and carbonic anhydrase inhibitors, making this allergy less concerning for this prescription.
D. Sulfonamide: Dorzolamide contains a sulfonamide component, and clients with a sulfonamide allergy are at risk for hypersensitivity reactions such as rash, conjunctivitis, or even systemic effects. Reviewing the medical record for a sulfonamide allergy is essential before administration to prevent serious complications.
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