The nurse is caring for a client diagnosed with a fractured tibia and fibula.Which data should the nurse report to the healthcare provider immediately?
Dorsalis pedis pulse cannot be located with a doppler and increasing pain.
Pain relieved after administering 4 mgs of hydromorphone.
Generalized weakness and increasing sensitivity to touch.
Localized edema and discoloration of the affected limb.
The Correct Answer is A
Choice A rationale
Inability to locate the dorsalis pedis pulse and increasing pain are signs of compromised circulation, requiring immediate intervention.
Choice B rationale
Pain relieved by medication does not indicate an urgent situation and suggests effective pain management.
Choice C rationale
Generalized weakness and increased sensitivity to touch are not typically indicative of a critical emergency requiring immediate reporting.
Choice D rationale
Localized edema and discoloration are expected findings following a fracture and do not necessitate immediate reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale
Serum creatinine is assessed annually to evaluate kidney function, as diabetes can lead to nephropathy and renal impairment.
Choice B rationale
Urine for microalbuminuria is important to detect early kidney damage, which can occur in diabetic nephropathy.
Choice C rationale
Hearing (audio) exam is not a standard annual test for diabetic complications. Diabetes primarily affects the vascular system, kidneys, and nerves.
Choice D rationale
Chest x-ray is not routinely performed annually for diabetes management. It is used when there are specific indications such as respiratory symptoms.
Choice E rationale
Monofilament testing of the foot is conducted annually to detect diabetic neuropathy and prevent foot ulcers and infections.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Lying down after meals can increase the risk of acid reflux in individuals with a hiatal hernia. Patients are often advised to remain upright after eating to minimize symptoms.
Choice B rationale
Elevating the head of the bed helps prevent gastric contents from refluxing into the esophagus, reducing symptoms of hiatal hernia and promoting better sleep.
Choice C rationale
Reducing caffeine and spicy foods can help manage symptoms, as these substances can irritate the stomach lining and exacerbate reflux in hiatal hernia patients.
Choice D rationale
Maintaining a healthy weight is important because excess weight can increase abdominal pressure and contribute to the worsening of hiatal hernia symptoms.
Choice E rationale
Drinking less fluid is not typically a recommendation for hiatal hernia. Adequate hydration is important for overall health, and reducing fluid intake may not have a significant impact on symptoms.
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