The same patient reports that he was able to sleep through the night.
However, he notes continued numbness in his left arm, along with a tingling sensation, and is not able to move his fingers.
He also reports mild nausea and has no desire to eat breakfast.
There is a 3 cm by 5 cm area of blood noted on the bandage.
His left arm is warm to touch.
His left shoulder and collarbone are symmetric.
As a nurse, which findings would indicate that the patient is progressing as expected?

The patient was able to sleep through the night.

The patient’s left arm is warm to touch.

The patient’s left shoulder and collarbone are symmetric.

The patient has no desire to eat breakfast.

Answer and Explanation

Correct Answer : A,B,C

Choice A rationale

The patient was able to sleep through the night. This is a positive sign as it indicates that the patient is comfortable and not in distress. Sleep is essential for healing and recovery.

Choice B rationale

The patient’s left arm is warm to touch. This could indicate that there is adequate blood flow to the area, which is necessary for healing. However, warmth could also be a sign of inflammation or infection, so it’s important to monitor this closely.

Choice C rationale

The patient’s left shoulder and collarbone are symmetric. This is a good sign as it indicates that there is no obvious dislocation or fracture, which could cause pain and limit mobility.

Choice D rationale

The patient has no desire to eat breakfast. This is not necessarily a sign of progress. Loss of appetite can be a symptom of many conditions, including stress, infection, or certain medications. It’s important to encourage the patient to eat to maintain strength and support healing.

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

Explanation

Choice A rationale

Checking capillary refill on bilateral upper extremities can help assess peripheral circulation and identify any potential vascular injuries.

Choice B rationale

Administering morphine 2 mg IV as ordered would help manage the patient’s pain.

Choice C rationale

Performing range of motion exercises may not be appropriate immediately after the fall and before the extent of the patient’s injuries are fully assessed.

Choice D rationale

Administering ondansetron 4 mg IV as ordered can help manage any nausea or vomiting that the patient may experience, which can be a side effect of the morphine or a result of the fall itself. TemazepamTemazepam Explore

A. Apply ice, then a warm compress to the IV site. B. Check the medical record for the date of IV insertion. C. Redress the IV site while checking for redness. D. Discontinue the current IV site and insert a new one.

Correct Answer is D

Explanation

Choice A rationale

Applying ice, then a warm compress to the IV site may help with pain or inflammation, but it does not address the potential problem with the IV site itself. If the client is experiencing pain and refuses a flush to assess the site, it could indicate that the IV site is compromised.

Choice B rationale

Checking the medical record for the date of IV insertion could provide useful information about how long the IV has been in place, but it does not directly address the client’s current complaint of pain at the IV site.

Choice C rationale

Redressing the IV site while checking for redness could help identify signs of infection or inflammation, but it does not address the client’s complaint of pain or their refusal to have the site flushed.

Choice D rationale

Discontinuing the current IV site and inserting a new one is the most appropriate action in this situation. If the client is experiencing pain at the IV site and refuses a flush to assess the site, it suggests that the current IV site may be compromised. Inserting a new IV ensures that the client can continue to receive their scheduled IV medication safely.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

As a nurse, you are reviewing the orders and planning initial steps for caring for the same patient.Which interventions should you perform?

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

Explanation

While preparing to administer a scheduled IV medication, a client complains of pain at the IV site and refuses a flush to assess the site.What should the nurse do next?

Correct Answer is D

Explanation

Exhibits After the nurse assesses the client, the healthcare provider writes prescriptions. The nurse reviews the prescriptions. Which 2 prescriptions should the nurse complete first?

The nurse is reviewing the nurse’s notes and flow chart to identify trends.Which notations require immediate follow-up?

A newly recruited unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs.What intervention should the home health nurse implement to ensure adequate care for all clients?

An older adult client with dementia is refusing to allow an unlicensed assistive personnel (UAP) to assist in bathing.The client is becoming increasingly agitated and stating the UAP “wants to hurt me and tie me up.”. Which approach should the nurse use with this client?

A patient arrives at the emergency department experiencing chest pain after taking sildenafil.Based on the patient’s history, which medication should the nurse withhold?

An older adult client informs the nurse of having a high-density lipoprotein (HDL) level of 85 mg/dL (2.2 mmol/L). What action should the nurse take?

When conducting diet teaching for a client who was diagnosed with hypertension, which food(s) should the nurse encourage the client to eat? Select all that apply.

A 33-year-old female client, who denies smoking, drinking, or using any illicit drugs, exercises 2 to 3 times per week and has an office job.She weighs 68 kg and is 156 cm tall.Which of the following actions would be effective in maintaining her energy balance?