A client sustained a left femur fracture 3 hours ago. Initial vital signs and assessment were within normal limits with the exception of left leg pain.
The nurse re-assesses the client and documents the following:
- Temp: 37.2 C Pain: 7/10-chest 5/10 left leg.
- Pulse: 110 bpm
- Respirations: 40 breaths per min, labored 02 saturation: 88%
- Neuro: A&O x 3. Anxious Skin: Petechiae to neck and anterior chest.
Based on this assessment, which action is appropriate at this time?
Notify the healthcare provider that the client's pain is not well-managed
Reassure the client that the pain and stress of the fracture will soon get better.
Order a chest CT Computerized Tomography) to rule out a pulmonary embolus (PE).
Notify the healthcare provider that the client may have a fat embolism
The Correct Answer is D
Fat embolism syndrome can occur when fat globules enter the bloodstream after a long bone fracture, such as a femur fracture. The fat globules can travel to the lungs and cause respiratory distress and decreased oxygen saturation. The symptoms observed in the client, including tachypnea (labored breathing), decreased oxygen saturation (88%), and the presence of petechiae (small red or purple spots) on the neck and anterior chest, are consistent with fat embolism syndrome.
Fat embolism syndrome is a serious condition that requires immediate medical attention. Notifying the healthcare provider allows for prompt evaluation, confirmation of the diagnosis, and initiation of appropriate treatment. This may involve further diagnostic tests such as a chest CT scan, as mentioned in one of the options, to rule out other potential causes or complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A likely cause of a low sodium level (hyponatremia) of 128 mEq/L is the administration of hypotonic IV fluids. Hypotonic IV fluids have a lower concentration of solutes compared to the body's fluids, which can lead to dilutional hyponatremia. When these fluids are administered, they can cause water to move into the cells, diluting the sodium concentration in the bloodstream.
Correct Answer is B
Explanation
Acute adrenal insufficiency, also known as adrenal crisis, is characterized by low levels of adrenal hormones, particularly cortisol. One of the primary manifestations of adrenal insufficiency is electrolyte imbalance, specifically hyponatremia (low sodium) and hyperkalemia (high potassium). Inadequate cortisol levels can lead to impaired sodium reabsorption in the kidneys, resulting in sodium loss and low serum sodium levels.
When the patient receives appropriate therapies for acute adrenal insufficiency, such as administration of glucocorticoids (e.g., hydrocortisone), the cortisol levels begin to normalize. As a result, the impaired sodium reabsorption improves, leading to an increase in serum sodium levels.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today