A client has a leg cast following an open reduction for a fractured tibia. Approximately two hours after returning to the unit, the client reports severe pain in the affected extremity, and the nurse observes that the limb is blue and blanched. Which action should the nurse perform first?

Record the observations and check the limb every 15 minutes.

Release the traction and notify the healthcare provider.

Notify the healthcare provider of the assessment findings.

Administer a PRN pain medication routinely as prescribed.

Answer and Explanation

The Correct Answer is C

Choice A reason: Documenting and monitoring are important, but delaying intervention in the presence of signs of compartment syndrome can lead to irreversible damage.
Choice B reason: Releasing traction without provider direction may be unsafe and is not the nurse’s first independent action.
Choice C reason: Notifying the healthcare provider immediately is critical. Severe pain, discoloration, and blanching suggest compromised circulation, possibly compartment syndrome, which requires urgent evaluation and intervention.
Choice D reason: Administering pain medication may mask symptoms and delay necessary treatment. Pain unrelieved by medication is a red flag for ischemia.

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Correct Answer is A

Explanation

Choice A reason: Dyspnea and sinus tachycardia may indicate fluid overload or pulmonary edema, which are life-threatening complications of AKI and require urgent intervention.
Choice B reason: While infection is concerning, respiratory and cardiac symptoms take precedence due to their potential for rapid deterioration.
Choice C reason: Low, concentrated urine output is expected in AKI but does not require immediate action unless accompanied by other critical signs.
Choice D reason: A bad taste in the mouth may be related to uremia but is not an urgent symptom compared to respiratory distress.

A. Tea and hot chocolate. B. Citrus fruit juices. C. Low sodium soups. D. Overall fluid intake.

Correct Answer is A

Explanation

Choice A reason: Tea and hot chocolate contain oxalates, which can contribute to the formation of calcium oxalate stones—the most common type of urinary tract calculi. Limiting these beverages helps reduce recurrence risk.

Choice B reason: Citrus juices, especially those high in citrate like lemonade and orange juice, can help prevent stone formation by inhibiting crystallization of calcium and oxalate. They are generally encouraged.

Choice C reason: Low sodium soups are not contraindicated unless the client has other conditions requiring sodium restriction. Sodium can increase calcium excretion, but the soup itself is not a primary concern unless consumed excessively.

Choice D reason: Overall fluid intake should not be limited. In fact, increasing fluid intake—especially water—is the most effective strategy to prevent stone recurrence by diluting urinary solutes and promoting regular voiding.

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A client has a leg cast following an open reduction for a fractured tibia. Approximately two hours after returning to the unit, the client reports severe pain in the affected extremity, and the nurse observes that the limb is blue and blanched. Which action should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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