A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?

Correct Answer: C

Rationale: The most pertinent nursing diagnosis for the patient with a right femur fracture stabilized in a full leg cast is "Acute pain" (Choice C). The rationale for this is as follows: 1. The patient is experiencing moderate discomfort due to the fracture and immobilization in the cast, indicating a need for pain management. 2. Acute pain is a priority in this situation as it can impact the patient's comfort, mobility, and overall recovery. 3. Managing pain effectively is crucial for promoting healing, preventing complications, and improving the patient's quality of life. 4. Posttrauma syndrome (Choice A) may be a consideration in the long term but is not the immediate priority. Constipation (Choice B) is not the most pertinent nursing diagnosis in this scenario. Anxiety (Choice D) may be present but addressing pain is more urgent and directly related to the patient's current condition.

Correct Answer: C

Rationale: The correct answer is C: Acute pain. This is the most pertinent nursing diagnosis because the patient has a right femur fracture and reports moderate discomfort. The priority is to address the acute pain associated with the fracture. Posttrauma syndrome (A) typically involves a broader range of emotional and psychological responses beyond just moderate discomfort. Constipation (B) is not the priority in this case, as it is not directly related to the patient's current condition. Anxiety (D) may be present but addressing the acute pain takes precedence in this situation to ensure the patient's comfort and well-being.

Correct Answer: B

Rationale: Rationale: 1. Discharge planning should start at admission to ensure comprehensive preparation. 2. Early planning allows for assessment of needs and coordination of resources. 3. It promotes continuity of care and reduces risks of readmission. 4. Options A, C, and D are incorrect as they miss the opportunity for proactive planning.

Correct Answer: C

Rationale: The correct answer is C: Glucagon. In a hypoglycemic reaction, glucagon can be administered to raise blood sugar levels quickly. Glucagon works by stimulating the liver to release stored glucose into the bloodstream. This is crucial in emergencies when oral carbohydrates are not feasible. Epinephrine (A) is used for severe allergic reactions, not hypoglycemia. 50% dextrose (B) is an oral carbohydrate used for hypoglycemia but is not always practical. Hydrocortisone (D) is a corticosteroid used for inflammatory conditions, not for hypoglycemic emergencies.

Correct Answer: A

Rationale: The correct answer is A: Secure the cannula with tape. This is the last step in inserting an IV cannula to ensure it stays in place and prevents dislodgement or movement. Securing the cannula with tape helps maintain proper positioning and prevents accidental removal. Documenting the insertion site, date, and type of cannula used (B) is important but typically done earlier in the process. Assessing the site (C) should be done before securing the cannula to ensure proper placement. Placing a sterile dressing over the insertion site (D) is also important, but it usually comes before securing the cannula with tape to maintain a clean and sterile environment.

Correct Answer: C

Rationale: The correct answer is C: "Take zidovudine every 4 hours around the clock." Zidovudine is an antiretroviral medication used to treat HIV/AIDS. It is crucial for the client to adhere to the prescribed dosing schedule to maintain therapeutic blood levels. Taking the medication every 4 hours around the clock helps to ensure consistent levels in the body, maximizing its efficacy. Taking it with meals (choice A) or on an empty stomach (choice B) is not specifically indicated for zidovudine. Choice D is incorrect as taking OTC drugs without consulting a healthcare provider can lead to drug interactions or adverse effects. Hence, choice C is the most appropriate instruction to ensure the client benefits from the medication.

Correct Answer: B

Rationale: The correct answer is B: Purplish discoloration of hands and feet. Hand-foot syndrome in sickle cell anemia is characterized by pain, swelling, and purplish discoloration of the hands and feet due to vaso-occlusive crisis. Unequal growth of fingers and toes (A), webbing between fingers and toes (C), and deformities of wrists and ankles (D) are not typical findings associated with hand-foot syndrome in sickle cell anemia.

Correct Answer: B

Rationale: The correct answer is B: Protein. Antibodies are a type of protein produced by the immune system to help identify and neutralize pathogens like bacteria and viruses. Proteins are composed of amino acids, which are the building blocks of proteins. Antibodies have a specific structure that allows them to bind to specific antigens. Fat (A), Sugar (C), and Carbohydrates (D) are not primary components of antibodies and do not play a significant role in their structure or function.

Correct Answer: A

Rationale: The correct answer is A: 2 and 5. Diminished breath sounds indicate possible atelectasis or pneumonia post-operatively, making coughing and deep breathing (2) and ambulation (5) crucial to prevent complications. Decreasing fluid intake (iv) can lead to dehydration, worsening the situation. Administering antibiotics (i) without further assessment may not be necessary at this point. Acetaminophen (iii) can help with fever but does not address the underlying respiratory issue.