A client sustained fractures of the right ulna and radius in a motor vehicle accident. The nurse suspects compartment syndrome. Which assessment should be performed immediately to evaluate for this complication?
Assess the range of motion of the affected wrist and fingers.
Palpate the pulse on the affected extremity.
Measure the circumference of the affected limb.
Assess for pain with passive movement of the fingers.
The Correct Answer is D
Choice A reason: Assessing range of motion may provide general information about joint function but is not specific or sensitive for detecting compartment syndrome. It may also be contraindicated due to pain or instability from the fracture.
Choice B reason: Palpating the pulse is important but not the most sensitive early indicator of compartment syndrome. Pulses may remain intact until late stages, making this an unreliable early assessment.
Choice C reason: Measuring limb circumference can detect swelling but does not confirm compartment syndrome. It lacks specificity and may not reflect internal pressure changes accurately.
Choice D reason: Pain with passive movement of the fingers is the most sensitive early sign of compartment syndrome. It reflects increased intracompartmental pressure affecting muscle and nerve tissue, and should prompt immediate evaluation and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: While this statement acknowledges the elevated reading, it prematurely implies a diagnosis and risk without confirming through repeated measurements. Hypertension diagnosis requires multiple readings over time.
Choice B reason: This response is dismissive and inaccurate. A reading of 146/96 mm Hg is considered stage 2 hypertension and warrants further evaluation, not reassurance without context.
Choice C reason: Although hypertension is common among males, this response lacks clinical relevance and does not address the client’s concern about treatment or diagnosis.
Choice D reason: This is the most accurate and evidence-based response. A single elevated reading does not confirm hypertension. Diagnosis requires multiple elevated readings on separate occasions, ideally under standardized conditions.
Correct Answer is A
Explanation
Choice A reason: Pursed-lip breathing helps maintain airway patency, prolongs exhalation, and improves gas exchange. It is a cornerstone technique in COPD management.
Choice B reason: High-flow oxygen via non-rebreather mask may suppress respiratory drive in COPD clients who retain CO₂. Oxygen should be titrated carefully to maintain safe saturation levels.
Choice C reason: Bronchodilators are typically administered before meals to improve breathing and reduce fatigue during eating. Delaying until after meals may not optimize therapeutic benefit.
Choice D reason: Lying flat can impair diaphragmatic movement and worsen ventilation. Upright or semi-Fowler’s positioning is preferred to enhance lung expansion.
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