The nurse is preparing a client for surgery who was admitted from the emergency department following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin sodium 5,000 units SUBQ daily. Which nursing action is a priority?

Have the client sign the surgical and transfusion permits.

Notify the healthcare provider of the client's medication history.

Ensure that the potential for bleeding is explained to the client.

Observe the heparin injections sites for signs of bruising.

Answer and Explanation

The Correct Answer is B

A. Having the client sign surgical and transfusion permits is important but not the priority in this situation.

B. Notifying the healthcare provider of the client's medication history, including heparin use, is crucial to ensure appropriate perioperative management and to prevent excessive bleeding during surgery.

C. Explaining the potential for bleeding to the client is important for informed consent but is not the priority in this situation.

D. Observing the heparin injection sites for signs of bruising is important but not the priority compared to notifying the healthcare provider about the client's medication history.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Palpitations and shortness of breath are symptoms of thyrotoxicosis, indicating excessive thyroid hormone levels, which could result from an overdose of levothyroxine sodium.

B. Bradycardia and constipation are more indicative of hypothyroidism, which would suggest the need for an increase in levothyroxine dosage rather than a decrease.

C. Muscle cramping and dry, flushed skin are symptoms of hypothyroidism, which would suggest inadequate thyroid hormone replacement rather than excess.

D. Lethargy and lack of appetite are also symptoms of hypothyroidism, not hyperthyroidism, which would not typically result from an overdose of levothyroxine.

A. Plan to assess the client's cognition after returning to the room. B. Confirm that this is an effective technique to help with ambulation. C. Assist the client to a carpeted area to walk more easily. D. Reorient the client to the present location and circumstances.

Correct Answer is B

Explanation

A. Assessing the client's cognition may be appropriate if there are concerns about cognitive function, but in this scenario, the client's response indicates a coping mechanism for freezing episodes rather than cognitive impairment.

B. Confirming that the client's technique of pretending to step over a crack is an effective strategy acknowledges the client's self-initiated coping mechanism for freezing episodes, which can help promote independence in ambulation.

C. Assisting the client to a carpeted area may help reduce the risk of falls but does not directly address the freezing episode or the client's coping strategy.

D. Reorienting the client to the present location and circumstances is unnecessary as the client's response indicates a conscious coping strategy rather than confusion or disorientation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?

Correct Answer is A

Explanation

The nurse assists a client with Parkinson's disease to ambulate in the hallway. The client appears to "freeze" and then carefully lifts one leg and steps forward. The client tells the nurse of pretending to step over a crack on the floor. How should the nurse respond?

Correct Answer is B

Explanation

Which dietary instruction is most important for the nurse to explain to a client who has had gastric bypass surgery?

A client with a renal calculus reports severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority?

The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?

When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include?

The nurse is caring for a client that is unconscious and having seizures. Which nursing intervention is most essential in this client's plan of care (POC)

The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of a compromised peripheral arterial circulation of the lower extremity?

A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently bum and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?

The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. Which action should the nurse take?