The nurse is assessing a client who recently returned from surgery for a femur fracture. The client begins to complain of pain, numbness, and tingling to the affected extremity. Upon assessment, the extremity is cold to the touch with no pedal pulse and no motor function. Which of the following actions should the nurse take? (Select all that apply)

Apply a constricting bandage/gauze wrap

Advise the client they will need an immediate amputation

Prepare the client to go back to the operating room

Elevate the extremity and apply ice

Notify the surgeon

Answer and Explanation

Correct Answer : C,E

A. Applying a constricting bandage/gauze wrap is contraindicated. This could further compromise circulation and exacerbate ischemia.
B. Advising the client about an immediate amputation is inappropriate and outside the nurse's scope of practice. The focus should be on timely intervention and notifying the surgeon.
C. Preparing the client to go back to the operating room is appropriate because the symptoms indicate potential compartment syndrome or vascular compromise, which often requires surgical intervention to restore circulation.
D. Elevating the extremity and applying ice is contraindicated in this scenario. Elevation can further decrease blood flow to an already ischemic limb, and ice application can cause vasoconstriction, worsening the issue.
E. Notifying the surgeon is essential. The described symptoms are a surgical emergency requiring immediate evaluation and intervention to prevent permanent damage.

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Correct Answer is A

Explanation

A. Upper UTI refers to infections that affect the kidneys (pyelonephritis) and ureters. These infections are typically more serious and can lead to kidney damage if not treated promptly.
B. Lower UTI refers to infections that affect the bladder (cystitis) or urethra (urethritis), which are generally less severe than upper UTIs.
C. Urosepsis is a severe, systemic infection that results from a UTI that has spread to the bloodstream. It can occur with either upper or lower UTIs.
D. Uncomplicated UTI refers to a straightforward infection of the urinary tract, typically involving the bladder, in an otherwise healthy individual. It is not specifically related to the kidneys or ureters.

A. Urine output of 32 mL/hour. B. Confusion and disorientation. C. Blood pressure of 106/82. D. 2+ pedal edema bilaterally.

Correct Answer is B

Explanation

A. A urine output of 32 mL/hour is slightly below the normal threshold (30 mL/hour) but does not indicate an immediate threat requiring intervention.
B. Confusion and disorientation are signs of severe hyponatremia, which can lead to cerebral edema and life-threatening complications such as seizures or coma. This finding requires immediate intervention to prevent worsening neurological impairment.
C. A blood pressure of 106/82 is within an acceptable range and does not indicate a critical issue in this context.
D. Bilateral 2+ pedal edema is not uncommon in elderly clients and does not directly indicate a severe complication of hyponatremia requiring immediate action.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which classification of urinary tract infection (UTI) is described as infection of the kidneys and ureters?

Correct Answer is A

Explanation

The nurse is assessing an elderly client admitted for hyponatremia. Which of the following findings requires immediate intervention?

Correct Answer is B

Explanation

The nurse is caring for a client who was admitted for an acute exacerbation of Crohn's Disease with severe diarrhea for the last two days. The nurse knows that which of the following is the priority risk for this client?

A client presents to the emergency department with complaints of urinary frequency, dysuria, and fever. Which of the following orders should the nurse carry out first?

The nurse is reviewing laboratory results for a client admitted for renal failure and notes the following: Sodium 144 mEq/L and Potassium 6.6 mEq/L. Which of the following should be the priority intervention?

The nurse should explain that which of the following medications puts a client at risk for developing hyperkalemia?

A nurse is planning care for a client who has dehydration and is receiving a continuous IV infusion of 0.9% sodium chloride. Which of the following interventions should the nurse include in the plan of care?

Which of the following statements regarding hypertonic (3%) sodium chloride is correct?