The nurse is caring for a patient who has a displaced midshaft fracture of the left femur and is in balanced suspension skeletal traction with 35 pounds of weights. The patient reports calf pain with right foot dorsiflexion
Which of the following actions would be most appropriate for the nurse to take?
a. Notify the RN.
b. Encourage dorsiflexion more frequently.
c. Check the traction setup.
d. Reduce 5 pounds of weight.
ANS: B
B. Patients facing surgery and especially a body image changing surgery such as amputation will experience anxiety. Interventions to aid with this anxiety should be planned. A, C, and D would all be potential postoperative nursing diagnoses after the surgery has occurred.
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A nurse assesses a client who is hospitalized for botulism. The client's vital signs are temperature: 99.8 ° F (37.6 ° C), heart rate: 100 beats/min, respiratory rate: 10 breaths/min, and blood pressure: 100/62 mm Hg. Which action should the nurse take?
a. Decrease stimulation and allow the client to rest. b. Stay with the client while another nurse calls the provider. c. Increase the client's intravenous fluid replacement rate. d. Check the client's blood glucose and administer orange juice.
A patient presents at the free clinic complaining of nervousness, worrying about everything, and feeling very tense. What diagnose would the nurse suspect?
A) Neurosis B) Psychosis C) Anxiety D) Depression
While assisting with the surgical removal of an adrenal tumor, the OR nurse is aware that the patient's vital signs may change upon manipulation of the tumor. What vital sign changes would the nurse expect to see?
A) Hyperthermia and tachypnea B) Hypertension and heart rate changes C) Hypotension and hypothermia D) Hyperthermia and bradycardia
During a daily weight the nurse notes that a client has lost 0.4 kilograms. How many grams of weight should the nurse document that this client has lost in one day?
1. 0.004 2. 0.04 3. 40 4. 400