The nurse is caring for a client with acute osteomyelitis in the left lower extremity secondary to a traumatic foot injury. Which assessment should the nurse complete first?

Left femoral pulse volume.

Pain characteristics on the left leg.

Range of motion in the left leg.

Circumference of the left calf.

Answer and Explanation

The Correct Answer is B

A. Assessing peripheral pulses is important to evaluate circulation and detect compromised blood flow. However, in acute osteomyelitis, circulation is usually not immediately life-threatening unless there are signs of compartment syndrome or vascular compromise.

B. Pain is the most critical assessment in acute osteomyelitis. Sudden worsening pain, especially if severe or unrelieved by medication, may indicate complications such as abscess formation, increased infection, or early compartment syndrome, which require prompt intervention. Evaluating pain first allows the nurse to prioritize immediate interventions to prevent further tissue damage or systemic infection.

C. While assessing joint mobility helps identify functional limitations and guide rehabilitation, it is secondary to evaluating pain and potential infection complications. Moving the affected limb before addressing pain could worsen discomfort or injury.

D. Measuring calf circumference is useful to monitor swelling or edema, which can indicate infection progression or vascular issues. However, this is a secondary assessment compared to evaluating acute pain that could signal serious complications.

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Correct Answer is ["A","C","D"]

Explanation

A. Pharmacologic therapy is a cornerstone of GERD management. The client was prescribed famotidine, an H2 receptor antagonist, which reduces gastric acid production and alleviates symptoms. Including medications in the plan of care ensures the nurse monitors effectiveness, educates the client on proper timing and dosing, and evaluates for side effects.

B. Surgery is generally reserved for clients with severe GERD, complications (e.g., strictures, Barrett’s esophagus), or those who do not respond to lifestyle modifications and medication therapy. The current presentation does not indicate the need for surgical intervention at this stage.

C. Dietary modifications are essential for symptom management in GERD. Recommendations include avoiding foods that trigger reflux (e.g., fatty or fried foods, chocolate, caffeine, spicy foods), eating smaller meals, and not lying down immediately after eating. Nutrition planning also helps address the client’s obesity, which is a risk factor for GERD.

D. Lifestyle interventions are critical in GERD management. These include weight reduction (the client has a BMI of 37.8 kg/m²), smoking cessation (the client smokes 1 pack per week), elevating the head of the bed, and avoiding tight clothing. These modifications can reduce symptom frequency and severity.

E. Endoscopic interventions are typically reserved for clients with complications or refractory GERD that does not respond to medications and lifestyle changes. There is no current indication for this client to undergo endoscopic therapy.

A. Remove dentures or other oral appliance. B. Elevate the head of the bed to a 45-degree angle. C. Lift and lock the side rails in place. D. Apply the client's positive airway pressure device.

Correct Answer is D

Explanation

A. While removing dentures may be necessary for some oral procedures or to prevent choking if they are loose, it does not address the primary concern in this scenario, which is the risk of airway obstruction or respiratory depression caused by morphine in a client with OSA. Removing dentures does not improve oxygenation or ventilation and therefore is not a priority.

B. Raising the head of the bed can help reduce upper airway obstruction by improving the mechanics of breathing in clients with OSA. Elevation may also help with comfort and reduce the risk of aspiration. While this is beneficial, it does not provide the continuous airway support needed for a client who has received an opioid, which depresses respiratory drive and increases the likelihood of airway collapse.

C. Ensuring that side rails are up is a safety measure to prevent falls, particularly in clients who may become drowsy or confused after receiving medications like morphine. Although important for overall safety, this intervention does not address the most immediate risk of airway compromise or hypoventilation, which could be life-threatening.

D. This is the most critical intervention. Clients with OSA are prone to airway collapse during sleep or sedation, and opioids like morphine further depress the central respiratory drive, increasing the risk of apnea and hypoxemia. Using a CPAP or BiPAP device maintains airway patency, improves oxygenation, and reduces the risk of respiratory compromise. Applying the device before leaving the client ensures that ventilation is supported continuously and that the client is protected from potentially life-threatening respiratory events while unattended.

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The nurse is caring for a client with acute osteomyelitis in the left lower extremity secondary to a traumatic foot injury. Which assessment should the nurse complete first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","C","D"]

Explanation

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Correct Answer is D

Explanation

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