Nokea
Which of the following should lead the nurse to suspect that a client with a fracture of the right femur may be developing a fat embolus?
- A. Acute respiratory distress syndrome.
- B. Migraine-like headaches.
- C. Numbness in the right leg.
- D. Muscle spasms in the right thigh.
Correct Answer: A
Rationale: Fat embolism commonly presents with acute respiratory distress, a life-threatening complication of femoral fractures.
You may also like to solve these questions
A nurse is assessing a client with Addison's disease. The nurse should review laboratory reports for which of the following?
- A. Hypokalemia.
- B. Hypernatremia.
- C. Hypoglycemia.
- D. Decreased blood urea nitrogen (BUN) level.
Correct Answer: C
Rationale: Hypoglycemia is common in Addison's disease due to cortisol deficiency, which impairs gluconeogenesis.
The nurse is developing a plan to teach a client deep-breathing exercises to expand collapsed alveoli and prevent postoperative atelectasis and pneumonia. Which of the following steps should be included? Select all that apply.
- A. Splint or support the incision to promote maximal comfort.
- B. Inhale slowly through the nostrils; exhale through pursed lips.
- C. Hold the breath for about 5 seconds to expand the alveoli.
- D. Repeat this breathing method 5 to 10 times hourly.
- E. Close one nostril while inhaling.
Correct Answer: A,B,C,D
Rationale: Splinting the incision (A), slow nasal inhalation with pursed-lip exhalation (B), holding the breath (C), and repeating 5-10 times hourly (D) are correct steps for deep-breathing exercises to prevent atelectasis. Closing one nostril (E) is not part of this technique.
The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority?
- A. BP 110/62, atrial fibrillation with HR 82, bibasilar crackles.
- B. Confusion, urine output 15 mL over the last 2 hours, orthopnea.
- C. SpO2 92 on 2 liters nasal cannula, respirations 20, 1+ edema of lower extremities.
- D. Weight gain of 1 kg in 3 days, BP 130/80, mild dyspnea with exercise.
Correct Answer: B
Rationale: Confusion, low urine output, and orthopnea indicate severe heart failure with potential cerebral and renal hypoperfusion, requiring immediate intervention. Other options reflect stable or less urgent findings.
Two days after surgery, a client continues to take hydrocodone 7.5 mg and acetaminophen 500 mg (Lortab 7.5/500). What should the nurse ask the client before administering the pain medication?
- A. œWhere is your pain located?'
- B. œHave you emptied your bladder?'
- C. œHow long has it been since your last dose?'
- D. œIs your pain better than before you had surgery?'
Correct Answer: C
Rationale: Asking about the time since the last dose ensures safe administration, preventing overdose or toxicity, as hydrocodone has a specific dosing interval.
The nurse is a member of a team that is planning a client-centered approach to care of clients with chronic obstructive pulmonary disease (COPD) using the Chronic Care Model (CCM). The team should focus on improving quality of care and delivery in which of the following areas? Select all that apply.
- A. The community.
- B. Clinical information systems.
- C. Delivery system design.
- D. Administrative leadership.
- E. Emphasis on the acute care setting.
Correct Answer: A,B,C
Rationale: The Chronic Care Model emphasizes community resources (A), clinical information systems (B), and delivery system design (C) for chronic disease management. Administrative leadership and acute care focus are less central.