Nokea
Forty-eight hours after a patient sustained a fractured femur in a car accident, the nurse notes the patient has a pulse of 110, respirations at 25, labored respirations and crackles in both lung fields. The nurse immediately reports to the charge nurse the probability of which disorder?
- A. impending pneumonia.
- B. atelectasis.
- C. fat embolism.
- D. anxiety attack.
Correct Answer: C
Rationale: A pulmonary fat embolism involves the embolization of fat tissue with platelets and circulation of free fatty acids within the pulmonary circulation. Dyspnea, tachypnea, and chest pain are symptomatic of a fat embolus. These signs are not associated with impending pneumonia or atelectasis. The patient is undergoing a major complication; this is not an anxiety attack.
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Which patient statement indicates the need for additional teaching for a patient with rheumatoid arthritis who is taking meloxicam?
- A. I am keeping a daily record of my blood pressure.'
- B. I take aspirin before I go to bed.'
- C. I know I can take meloxicam with or without regard to meals.'
- D. I weigh every day so I will be aware of any weight gain.'
Correct Answer: B
Rationale: Aspirin or products containing aspirin should be avoided while taking meloxicam. While taking meloxicam, there is no reason to record blood pressure readings. This medication can be taken without regard to meals. Meloxicam does not cause weight gain.
What is the movement of an extremity away from the midline of the body called?
- A. Abduction
- B. Adduction
- C. Flexion
- D. Extension
Correct Answer: A
Rationale: Abduction is movement of an extremity away from the midline of the body.
When a patient recovering from a fractured tibia asks what callus formation is, the nurse provides which explanation?
- A. when blood vessels of the bone are compressed.
- B. a part of the bone healing process after a fracture when new bone is being formed over the fracture site.
- C. the formation of a clot over the fracture site.
- D. when the hematoma becomes organized and a fibrin meshwork is formed.
Correct Answer: B
Rationale: Callus formation occurs when the osteoblasts continue to lay the network for bone buildup and osteoclasts destroy dead bone. In compartment syndrome, blood vessels are compressed. Clot formation and hematoma organization occur in different phases of the bone healing process.
The nurse administering the drug colchicine for gout will give $0.5 \mathrm{mg}$ hourly for hours.
Correct Answer: 12
Rationale: Colchicine is given orally in a dose of $0.5 \mathrm{mg}$ for a period of 12 hours or until relief from pain is achieved or diarrhea occurs.
The patient that has a bipolar hip replacement following an intracapsular fracture has an order to be turned every 2 hours. The nurse understands that the correct nursing intervention is to keep the legs in which position?
- A. together so they do not separate while turning.
- B. flexed to stabilize the prosthesis.
- C. abducted so the prosthesis does not become dislocated.
- D. adducted to prevent additional pain for the patient with turning.
Correct Answer: C
Rationale: Nursing interventions also involve postoperative maintenance of leg abduction by using an abduction splint for 7 to 10 days to prevent dislocation of the prosthesis. Leg abduction does not involve keeping the legs together, flexion to stabilize the prosthesis or to keep the legs adducted to prevent additional pain with turning.