The nurse is preparing for a home visit to a patient with an external fixation device of the lower extremity. What priority care is anticipated?

Monitoring for infection

Monitoring circulatory status

Validating proper mobility

Checking discomfort level

Answer and Explanation

The Correct Answer is A

Correct answer: A
A. Monitoring for infection: Infection is a significant risk with external fixation devices due to the presence of pins that penetrate the skin and soft tissues. Monitoring for signs of infection, such as redness, swelling, discharge, or increased pain, is crucial.
B. Monitoring circulatory status: While circulatory status is important, especially in cases of limb injury or immobilization, it is not the most immediate concern compared to the risk of infection from the external fixation device.
C. Validating proper mobility: Ensuring proper mobility is important, but it is secondary to the prevention and detection of infection. Mobility assessments can be done after confirming that there are no infections or complications.
D. Checking discomfort level: While assessing discomfort is important for pain management and comfort, it is not as critical as monitoring for infection, which can lead to severe complications if not addressed promptly.

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Correct Answer is D

Explanation

A. Report a headache immediately: Headaches are not a common side effect of propranolol and may not require immediate reporting unless they are severe or unusual in nature.
B. Heart palpitations are common: Beta blockers like propranolol generally help to control heart palpitations and irregular heartbeats rather than cause them.
C. Monitor for bleeding gums: This is not a typical side effect of propranolol. Bleeding gums might be more related to dental issues or other medications.
D. Rise slowly to prevent dizziness: Propranolol can cause orthostatic hypotension, which is a drop in blood pressure upon standing up. Patients should be advised to rise slowly to prevent dizziness or fainting, which is a common side effect of beta blockers.

A. Has the patient been taking his medications as prescribed? B. Does the patient hurt anywhere else? C. When does the patient take his furosemide? D. Has the patient fallen before?

Correct Answer is D

Explanation

Has the patient been taking his medications as prescribed? This is the most important information to collect. Understanding the patient's medication adherence is crucial because if the patient is not taking his medications as prescribed, it could explain why his blood pressure is elevated. Noncompliance with medication regimens is a common cause of hypertensive urgency and can lead to severe complications. Therefore, knowing whether he has been taking his medications regularly and correctly would directly influence the management plan and help identify the cause of the current crisis.

Does the patient hurt anywhere else? While it’s important to assess for pain and discomfort to address immediate symptoms, this information does not directly address the potential cause of the elevated blood pressure. The patient already reported pain in the head, chest, and left leg, so the primary concern is managing his hypertensive urgency and understanding its underlying causes rather than identifying additional pain locations at this moment.

When does the patient take his furosemide? Knowing the timing of furosemide intake could provide insights into his diuretic therapy management and its potential impact on his blood pressure. However, it is less immediately relevant than understanding whether he has been taking all his medications as prescribed. This question might be more pertinent once medication adherence is confirmed to understand diuretic effects throughout the day.

Has the patient fallen before? This is relevant for assessing the risk of recurrent falls and potential underlying issues such as orthostatic hypotension or balance problems, which are crucial for long-term management and safety. However, it is not as immediately critical in the context of the current hypertensive urgency and the elevated blood pressure despite medication.

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The nurse is preparing for a home visit to a patient with an external fixation device of the lower extremity. What priority care is anticipated?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning care for patients with hypertension. What side effect should be included with teaching about the beta blocker propranolol (Inderal)?

Correct Answer is D

Explanation

Correct Answer is D

Explanation

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