The nurse cannot palpate a patient's pedal pulse following an open reduction internal fixation (ORIF) procedure for a fractured tibia. Which action is the priority intervention?
1. Check the lower extremity for pallor.
2. Notify the surgeon of the problem.
3. Assess the patient's pain rating.
4. Use a Doppler to find the pedal pulse.
4
Rationale 1: Pallor is not the best indicator of circulation status.
Rationale 2: Notifying the surgeon, if indicated, should occur once all assessment data are collected.
Rationale 3: A pain rating is not the best indicator of circulation status.
Rationale 4: To assess the circulation when the pulse is not palpable, the nurse should use a Doppler.
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The patient is admitted to the unit with the diagnosis of rhabdomyolysis. The patient is started on intravenous (IV) fluids and IV mannitol. Because mannitol is an osmotic diuretic, the nurse should:
a. assess the patient's hearing. b. assess the patient's lungs. c. decrease IV fluids once the diuretic has been administered. d. give extra doses prior to giving radiological contrast agents.
For a client in renal failure with an abnormally elevated serum potassium level, the priority assessment by the nurse would be the client's
a. electrocardiogram (ECG) strips. b. level of consciousness. c. serial BUN and creatinine levels. d. urine output.
The nurse is caring for a patient who is on strict isolation. Which statement indicates a break in technique?
a. Isolation supplies (gowns, masks, gloves) are placed inside the patient's room. b. The nurse washes her hands before applying cap, gown, and mask. c. Soiled linens are double-bagged. d. When leaving the patient's room, the nurse washes her hands for 10 minutes after removing gloves, mask, gown, and cap.
Yasmin causes less fluid retention because it:
1. blocks receptors for aldosterone. 2. blocks the calcium channels. 3. causes excretion of potassium ions. 4. prevents thirst.