The nurse reviews the prescriptions and plans initial steps for caring for the client.

Exhibits
Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response option selected.

Administer ondansetron 4 mg IV push.

Inspect the bandage for drainage.

Perform range of motion.

Check capillary refill on bilateral upper extremities.

Provide morphine 2 mg IV push.

Palpate and compare radial pulses.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Rationale:

Administer ondansetron 4 mg IV push: The client reports nausea and a history of vomiting, likely related to trauma, surgery preparation, and opioid use. Administering ondansetron will prevent aspiration, maintain hydration, and promote comfort during recovery.
Inspect the bandage for drainage: Observing the surgical dressing for bleeding or drainage is critical post-injury and postoperatively. It allows the nurse to identify early signs of hemorrhage, hematoma, or infection and report abnormalities promptly.
Check capillary refill on bilateral upper extremities: The left arm shows cool skin and diminished radial pulse (1+), suggesting compromised circulation. Checking capillary refill helps monitor perfusion and detect potential neurovascular compromise early.
Provide morphine 2 mg IV push: The client reports severe pain (10/10) from the humeral fracture. Administering prescribed opioids manages pain effectively, facilitates movement, and improves comfort, while allowing compliance with surgical positioning and procedures.
Perform range of motion: Active or passive range-of-motion exercises on the fractured left arm are contraindicated because the client has a displaced humeral head/neck fracture. Movement could worsen displacement, compromise neurovascular status, increase pain, and impede healing. The arm should remain immobilized until surgical fixation.
Palpate and compare radial pulses: Comparing pulses bilaterally assesses for neurovascular compromise in the injured limb. This is essential after fractures, especially with displacement, swelling, and diminished strength, to prevent ischemic complications.

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Correct Answer is D

Explanation

A. Measure abdominal girth: While this can detect abdominal distention or internal bleeding, it is not the immediate priority compared to assessing hemodynamic stability.

B. Observe for flushing: Flushing is not directly related to gastrointestinal bleeding and does not provide critical information about the client’s immediate risk.

C. Auscultate breath sounds: Although important for overall assessment, respiratory status is not the most urgent concern in a client with potential upper GI bleeding compared to monitoring for shock.

D. Obtain current vital signs: Coffee-ground emesis indicates possible upper gastrointestinal bleeding. The priority is to assess hemodynamic status, including blood pressure and heart rate, to determine if the client is experiencing hypovolemia or shock, which requires immediate intervention.

A. Sodium level 140 mEq/L (140 mmol/L). B. Potassium level 3.8 mg/dL (3.8 mmol/L). C. Calcium level 7.2 mg/dL (1.8 mmol/L). D. Oxygen saturation level 97%

Correct Answer is C

Explanation

Rationale:
A. Sodium level 140 mEq/L (140 mmol/L): This value is within the normal reference range and is unlikely to contribute to the development of a dysrhythmia. Sodium imbalances can affect cardiac function, but this level does not pose a risk.

B. Potassium level 3.8 mg/dL (3.8 mmol/L): Potassium is within the normal range (3.5–5.0 mEq/L) and would not typically precipitate a cardiac dysrhythmia. Hypokalemia or hyperkalemia outside of the normal range would be more concerning.

C. Calcium level 7.2 mg/dL (1.8 mmol/L): This value is below the normal range (8.4–10.6 mg/dL), indicating hypocalcemia. Low calcium levels can prolong the QT interval and increase the risk of ventricular dysrhythmias, making this the most likely contributing factor to the telemetry changes.

D. Oxygen saturation level 97%: This oxygen saturation is within the normal range and does not contribute to cardiac dysrhythmias. Adequate oxygenation reduces, rather than exacerbates, the risk of arrhythmias.

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The nurse reviews the prescriptions and plans initial steps for caring for the client. Exhibits Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response option selected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After being transferred from the emergency department (ED) to a medical unit, a client vomits into an emesis basin. The nurse observes the emesis as seen in the picture. Which assessment should the nurse complete first?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

A client receiving thyroid replacement therapy following a thyroidectomy is seen in the clinic for a 6 weeks postoperative check up. Which assessment is most important for the nurse to obtain?

The nurse assists a client with Parkinson's disease (PD) 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?

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

A client admitted with thyrotoxicosis is reporting a "pounding heart in the chest." Which assessment finding warrants immediate intervention by the nurse?

An adult client is admitted to the medical unit due to rectal bleeding after a colonoscopy in which a polyp was biopsied and cauterized. Which intervention should the nurse do first?

The drainage in the chest tube of a client with emphysema has changed from viscous green to clear watery fluid. Which action is best for the nurse to take?

The nurse reviews the prescriptions and plans initial steps for caring for the client.

Exhibits
Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response option selected.