The nurse is continuing to care for the adolescent.
Provider Prescriptions
1415:
X-ray of right leg shows open fracture of the right proximal tibia
Surgery consult
Morphine 4 mg IV every 2 hr as needed for pain.
The nurse is preparing the adolescent for the fasciotomy. Which of the following findings should the nurse report to the provider prior to surgery?
The adolescent's parents have concerns regarding the surgery.
The adolescent's blood pressure is 131/89 mm Hg.
The adolescent reports severe pain.
The adolescent has not voided in 4 hr.
The Correct Answer is A
A. Addressing parental concerns is crucial, especially for informed consent. If the parents are not comfortable or have unresolved questions, it could delay or prevent the surgery from proceeding.
B. While this blood pressure is slightly elevated, it is not an immediate concern that would typically prevent surgery.
C. Although severe pain is important to manage, it may not require immediate reporting unless it is unmanageable or indicates a serious problem.
D. While the lack of voiding in an immobile patient is a concern and could indicate urinary retention, it is not necessarily a finding that would prevent surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The frequency in which the client presses the call button is not a priority for the change-of-shift report, as it does not indicate the level of pain or comfort of the client. This choice is incorrect.
B. The client's most recent ventilator settings are not applicable, as the client was weaned from mechanical ventilation and no longer requires it. This choice is incorrect.
C. The time of the client's last dose of pain medication is important for the change-of-shift report, as it helps to ensure continuity of care and prevent under- or over-medication of the client. This choice is correct.
D. The last time the provider evaluated the client is not relevant for the change-of-shift report, as it does not reflect the current status of the client. This choice is incorrect.
Correct Answer is B
Explanation
A is incorrect because diarrhea is not an adverse effect of clonidine, but rather a symptom of other conditions such as infection, inflammation, or food intolerance.
B is correct because dry mouth is a common adverse effect of clonidine, which is an alpha-2 adrenergic agonist that reduces sympathetic nervous system activity.
C is incorrect because photophobia, or sensitivity to light, is not an adverse effect of clonidine, but rather a symptom of other conditions such as migraine, eye injury, or infection.
D is incorrect because bruising, or bleeding under the skin, is not an adverse effect of clonidine, but rather a symptom of other conditions such as coagulation disorders, vitamin deficiency, or trauma.
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