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    Hesi rn exit proctored examQuestion 30
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    Hesi rn exit proctored exam

    Patient Data Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response option selected.

    Explanation & Rationale

    Indicated: Palpate and compare radial pulses: Comparing radial pulses helps assess vascular integrity in both upper extremities, especially important with trauma and swelling. It can identify compromised circulation, which may occur with displaced fractures or vascular compression. Provide morphine 2 mg IV push: The client reports severe, constant pain (10/10) in the left arm. Morphine is prescribed and appropriate for controlling acute, post-traumatic pain and preventing complications related to stress and poor pain control. Administer ondansetron 4 mg IV push: The client reports nausea and fear of vomiting postoperatively. Ondansetron is an antiemetic used to prevent aspiration and reduce discomfort in post-op clients, especially those with limited mobility or recent anesthesia. Check capillary refill on bilateral upper extremities: Capillary refill is part of neurovascular assessment, which is essential in clients with fractures. It helps detect early signs of impaired perfusion or compartment syndrome, particularly when swelling or displacement is present. Inspect the bandage for drainage: Postoperative monitoring of the surgical site is critical to detect signs of bleeding, infection, or excessive drainage. Early inspection helps ensure prompt intervention if complications arise. Contraindicated: Perform range of motion: Performing ROM on a limb with a displaced humeral fracture is unsafe. Movement can worsen the fracture, increase pain, or disrupt surgical repairs, especially in the acute post-injury or post-op phase.

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