Patient Data
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 IVP.
Perform range of motion.
Provide morphine 2 mg IV push (IVP).
Inspect the bandage for drainage.
Check capillary refill on bilateral upper extremities.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}
• Palpate and compare radial pulses: Assessing radial pulses bilaterally is essential after humeral fracture and surgical repair because neurovascular compromise is a major complication. Detecting differences in pulse quality can help identify impaired circulation or compartment syndrome early.
• Administer ondansetron 4 mg IV: The client reports nausea postoperatively, which can increase discomfort and risk for aspiration. Ondansetron is prescribed and effective in controlling nausea by blocking serotonin receptors in the gut and brain, making it an appropriate intervention.
• Perform range of motion: With a displaced humeral head/neck fracture and immediate postoperative status, range-of-motion exercises are contraindicated. Movement of the joint could disrupt fixation, increase bleeding, or worsen pain. Immobilization and stabilization are priorities.
• Provide morphine 2 mg IV push (IVP): The client currently reports a pain level of 0/10 due to the preoperative nerve block. The order is PRN for pain > 7. Administering it now would be inappropriate and increase the risk of respiratory depression.
• Inspect the bandage for drainage: Checking the surgical bandage is necessary to monitor for bleeding or excessive drainage, which may indicate complications such as hemorrhage or infection. Since the order specifies not to remove the dressing, visual inspection only is the correct approach.
• Check capillary refill on bilateral upper extremities: Capillary refill helps evaluate peripheral perfusion, which is critical after orthopedic surgery. Comparing both extremities provides baseline data and helps detect vascular compromise that could threaten limb viability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
Rationale for correct choices:
• Respirations: Morphine is an opioid analgesic that can depress the respiratory center in the brainstem, leading to slowed breathing and hypoventilation. Monitoring respirations after administration is critical to detect early signs of opioid-induced respiratory depression.
• Ice application to the shoulder: Applying ice reduces swelling, pain, and inflammation by causing vasoconstriction and limiting fluid accumulation at the injury site. For an acute humeral fracture with significant swelling and bruising, cold therapy is the appropriate intervention.
Rationale for incorrect choices:
• Nausea: While morphine can cause nausea and vomiting as side effects, they are not the most life-threatening concerns compared to respiratory depression. Monitoring nausea is appropriate but not the priority when evaluating opioid safety.
• Blood pressure: Morphine can cause hypotension, but this effect is less common and typically secondary to respiratory depression and vasodilation. Continuous monitoring of blood pressure is helpful, but respiratory monitoring takes priority in detecting opioid complications.
• Early active range of motion: Active movement of the injured arm is not recommended immediately after a displaced humeral fracture, as it can worsen displacement and interfere with healing. Immobilization and stabilization are required before introducing range-of-motion exercises.
• Heat application to the shoulder: Heat increases blood flow to tissues, which can worsen swelling and bleeding in the acute phase of injury. Applying heat too soon after a fracture increases the risk of complications rather than reducing them.
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