The nurse is caring for a client with a fracture of the right humerus. Which assessment finding could be an early sign of a fat embolus?
Heat rash
Tachypnea
Bradycardia
Abdominal cramping
Confusion
The Correct Answer is B
Choice A reason: Heat rash is not an early sign of a fat embolus, as it is a skin condition that occurs when the sweat ducts are blocked and the sweat cannot evaporate. Heat rash is more common in hot and humid environments, and it causes red, itchy, or prickly bumps on the skin. Heat rash is not related to a fat embolus, which is a serious complication of a fracture that involves the release of fat droplets into the bloodstream.
Choice B reason: Tachypnea is an early sign of a fat embolus, as it indicates a respiratory distress that may be caused by the fat droplets blocking the pulmonary capillaries. Tachypnea is a rapid breathing rate that exceeds 20 breaths per minute, and it may be accompanied by dyspnea, chest pain, cough, or hemoptysis. Tachypnea is a sign of hypoxemia, which is a low level of oxygen in the blood, and it requires immediate intervention.
Choice C reason: Bradycardia is not an early sign of a fat embolus, as it is a slow heart rate that is below 60 beats per minute. Bradycardia may be caused by various factors, such as medication, heart disease, hypothyroidism, or vagal stimulation. Bradycardia is not related to a fat embolus, which is a serious complication of a fracture that involves the release of fat droplets into the bloodstream.
Choice D reason: Abdominal cramping is not an early sign of a fat embolus, as it is a pain or discomfort in the abdomen that may be caused by various factors, such as food intolerance, infection, inflammation, or obstruction. Abdominal cramping is not related to a fat embolus, which is a serious complication of a fracture that involves the release of fat droplets into the bloodstream.
Choice E reason: Confusion is not an early sign of a fat embolus, but a late sign that may indicate a cerebral involvement of the fat embolus. Confusion is a state of impaired awareness, orientation, or memory that may be caused by various factors, such as medication, infection, trauma, or hypoxia. Confusion is a sign of cerebral hypoxia, which is a low level of oxygen in the brain, and it requires immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Client with difficulty swallowing food and fluids who requires assistance with feeding is not an appropriate assignment for UAP. This client is at risk of aspiration and needs close monitoring and intervention by a licensed nurse.
Choice B reason: Client requiring a colostomy irrigation is not an appropriate assignment for UAP. This is a sterile procedure that involves inserting a catheter into the stoma and instilling fluid to flush out the bowel. This requires advanced skills and knowledge that are beyond the scope of practice of UAP.
Choice C reason: Client requiring vital signs immediately following open heart surgery is not an appropriate assignment for UAP. This client is in a critical condition and needs frequent and accurate assessment and evaluation by a licensed nurse.
Choice D reason: Client requiring a urine specimen collection is the most appropriate assignment for UAP. This is a routine and non-invasive task that can be delegated to UAP under the supervision of a licensed nurse.
Correct Answer is D
Explanation
Choice A reason: Asking the client to describe the purpose of the medication is not enough to evaluate the teaching-learning process. The client may know the rationale for the medication, but not how to use it correctly.
Choice B reason: Assessing the client's respiratory status at the next scheduled visit is not enough to evaluate the teaching-learning process. The client may have improved or worsened respiratory status due to other factors, not necessarily related to the use of the bronchodilator.
Choice C reason: Asking the client if they understand how to use the bronchodilator is not enough to evaluate the teaching-learning process. The client may say they understand, but not demonstrate the correct technique.
Choice D reason: Directly observing the client using the inhaler to give themselves a dose is the best way to evaluate the teaching-learning process. The nurse can assess the client's ability to use the inhaler correctly, and provide feedback and reinforcement as needed.
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