Nokea
A female client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that her distal pulses are diminished in the left foot. Which interventions should the nurse implement? (Select all that apply.)
- A. Offer ice chips and oral clear liquids
- B. Verify pedal pulses using a doppler pulse device
- C. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure
- D. Evaluate the application of the splint to the left leg
Correct Answer: B
Rationale: These interventions assess and address potential vascular compromise, which is critical in a client with a fractured femur.
You may also like to solve these questions
Drugs to be avoided in renal failure include:
- A. Allopurinol
- B. Digoxin
- C. Ceftazidime
- D. Acyclovir
Correct Answer: B
Rationale: Digoxin is avoided in renal failure due to its narrow therapeutic index and renal excretion, which can lead to toxicity.
The nurse is caring for a child who has undergone a cardiac catheterization. During recovery, the nurse notices the dressing is saturated with bright red blood. The nurse's first action is to:
- A. Call the interventional cardiologist
- B. Notify the cardiac catheterization laboratory that the child will be returning
- C. Apply a bulky pressure dressing over the present dressing
- D. Apply direct pressure 1 inch above the puncture site
Correct Answer: D
Rationale: Direct pressure above the puncture site helps control bleeding by localizing pressure over the vessel.
Concerning Ebstein-Barr virus (infectious mononucleosis):
- A. Presence of petechiae between the hard and soft palate supports the diagnosis
- B. Typically a rash following administration of penicillin V occurs
- C. Guillain-Barre syndrome is a recognised sequel
- D. Hepatitis is common
Correct Answer: A
Rationale: Petechiae between the hard and soft palate are a classic sign of infectious mononucleosis. A rash following penicillin V is also common, and Guillain-Barre syndrome is a rare complication.
What is cardiac power output (CPO) in a patient with acute anterior wall ST-elevation myocardial infarction and left ventricular failure? His mean arterial pressure was 60 mm Hg and cardiac output calculated on echo was 2.91l min−1.
- A. 0.48
- B. 0.38
- C. 0.58
- D. 0.68
Correct Answer: C
Rationale: Cardiac power output is calculated as (MAP × cardiac output) / 451. For the given values, the correct calculation gives a value of 0.58.
Which intervention should the nurse plan to decrease cardiac demands in an infant with congestive heart disease (CHD)?
- A. Organize nursing activities to allow for uninterrupted sleep.
- B. Allow the infant to sleep through feedings during the night.
- C. Wait for the infant to cry to show definite signs of hunger.
- D. Discourage parents from rocking the infant.
Correct Answer: A
Rationale: The infant requires rest and conservation of energy for feeding. Every effort is made to organize nursing activities to allow for uninterrupted periods of sleep. Whenever possible, parents are encouraged to stay with their infant to provide the holding, rocking, and cuddling that help children sleep more soundly. To minimize disturbing the infant, changing bed linens and complete bathing are done only when necessary. Feeding is planned to accommodate the infant’s sleep and wake patterns. The child is fed at the first sign of hunger, such as when sucking on fists, rather than waiting until he or she cries for a bottle because the stress of crying exhausts the limited energy supply. Because infants with CHD tire easily and may sleep through feedings, smaller feedings every 3 hours may be helpful.