HESI Compound Fracture – Flashcards
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If unable to reach Cora's Parents, what guidelines will determine the staff's ability to provide needed care?
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Emergency care may be provided after a reasonable attempt to reach the parents has been made
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Since Cora's parents whose are divorced, which parent should the nurse try to contact first?
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The parent who has been assigned legal custody of Cora by the court
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3. How is the presence of crepitus related to this femur fracture determined?
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Listen for grating sound when the affected area is moved
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What feature identifies Cora's fracture as an open fracture?
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Bone fragments protruding through the skin
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Implementation of which nursing intervention will reduce this risk?
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Initiate hourly assessment of Cora's foot distal to the fracture site
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What action should the nurse implement?
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Administer another dose of morphine immediately
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What volume of medication should the nurse administer?
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0.3 ml
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Which traction is a type of skeletal traction
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90-90 Femoral
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Which nursing intervention should be included in the plan of care while Cora is in traction?
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Ensure that the amount of weight remains consistent
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Which nursing intervention should be included in the plan of care to prevent this complication
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Cleanse around the pin site with half-strength hydrogen peroxide
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Which change in serum lab values would most likely indicate the onset of osteomyelitis?
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Increased erythrocyte sedimentation rate (ESR)
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which nursing action has the highest priority?
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assess the appearance of Cora's foot.
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What additional assessment should the nurse perform?
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Toe movement
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In addition to notifying the healthcare provider of this development, what action should the nurse implement?
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Obtain equiptment needed for cast removal
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Given the available nursing pesonnel, what staff assignment is best?
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Ongoing monitoring of Cora's foot by the LPN, while the UAP assists the postoperative client with crutches, and the RN determines if the new client has any immediate problems
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Which task should be delegated to the LPN at this time
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Spend time with Cora to distract her from the discomfort
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Which snack selection is the best choice for Cora while she is immobilized
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pudding
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What action should the nurse take?
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Give Cora a few crackers and stay with her while she eats them
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Which activity is the best choice for Cora?
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Pretend beauty palor
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How should the nurse respond to this situation?
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Support the mother's decision to hold Cora accountable for her own misbehavior
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What is the best response by the nurse?
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It is natural to be upset when your child expresses anger toward you
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In teaching the mother, what response should the nurse suggest she use with Cora
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I am sad that you are throwing things at me
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For which problem should Cora's parents be instructed to contact the health care provider?
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Warm spots are felt on the cast
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What action should the nurse take?
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Acknowledge that the parents have correctly learned how to move the cast while wet
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Which technique is most beneficial when preparing a preschooler for a procedure that may be frightening?
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Describe what the child will experience shortly before the procedure takes place
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How should the nurse respond?
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Instruct this parent that the child's age and size still require the use of a safety seat
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When an older child is sitting on a booster seat, where is the best place to locate the seat?
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Back seat of a car with lap and shoulder belts
