A nurse assesses a client with a fracture who is being treated with skeletal traction. Which assessment should alert the nurse to urgently contact the health provider?
a. Blood pressure increases to 130/86 mm Hg
b. Traction weights are resting on the floor
c. Oozing of clear fluid is noted at the pin site
d. Capillary refill is less than 3 seconds
ANS: B
The immediate action of the nurse should be to reapply the weights to give traction to the fracture. The health care provider must be notified that the weights were lying on the floor, and the client should be realigned in bed. The client's blood pressure is slightly elevated; this could be related to pain and muscle spasms resulting from lack of pressure to reduce the fracture. Oozing of clear fluid is normal, as is the capillary refill time.
You might also like to view...
A 50-year-old woman with elevated total cholesterol and triglyceride levels is visiting the clinic to find out about her laboratory results. What would be important for the nurse to include in patient teaching in relation to these tests?
a. The risks of undernutrition should be included. b. Offer methods to reduce the stress in her life. c. Provide information regarding a diet low in saturated fat. d. This condition is hereditary; she can do nothing to change the levels.
The client is prescribed amoxicillin (Amoxil) for 10 days to treat strep throat. After 5 days, the client tells the nurse he plans to stop the medication because he feels better. What is the best response by the nurse?
1. "If you stop the medicine early you have not effectively killed out the bacteria making you sick." 2. "You should get another throat culture if your symptoms return." 3. "If you stop the medicine early, this could result in resistance to the antibiotic." 4. "You should get another throat culture to see if the infection is gone."
The nurse will teach the patient beginning therapy with alfuzosin, an alpha-1 adrenergic blocking agent, to expect which common (and usually self-limiting) adverse effect(s)? (Select all that apply.)
a. Nausea b. Insomnia c. Dizziness d. Headache e. Lethargy f. Anorexia
Which common eye disorders should the nurse include in a teaching session for the parents of pediatric clients? Select all that apply
1. Hyperopia 2. Myopia 3. Astigmatism 4. Strabismus 5. Cataracts