A client with a fracture of the left arm that has been set in a cast complains of severe, diffuse pain that is unrelieved by pain medication. The nurse notes that the pulse distal to the site of injury has weakened and that the tissue is pale. Which of the following nursing actions should the nurse perform first?
Contact the health care provider.
Administer PRN pain medication.
Document the findings.
Elevate the extremity.
The Correct Answer is A
Choice A Reason: Contacting the health care provider is the first nursing action that the nurse should perform, as it indicates that the client may have compartment syndrome, which is a medical emergency that requires immediate intervention to prevent tissue necrosis and nerve damage.
Choice B Reason: Administering PRN pain medication is not the first nursing action that the nurse should perform, as it may not relieve the pain and may mask the symptoms of compartment syndrome.
Choice C Reason: Documenting the findings is not the first nursing action that the nurse should perform, as it may delay the treatment and worsen the outcome of compartment syndrome.
Choice D Reason: Elevating the extremity is not the first nursing action that the nurse should perform, as it may decrease blood flow and increase tissue ischemia in compartment syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: Side lying on the affected eye is not the correct position for the client after cataract surgery, as it may increase intraocular pressure and cause bleeding or damage to the surgical site.
Choice B Reason: Supine is not the correct position for the client after cataract surgery, as it may cause fluid accumulation and swelling in the eye.
Choice C Reason: Prone is not the correct position for the client after cataract surgery, as it may cause pressure and friction on the eye.
Choice D Reason: Semi Fowler's is the correct position for the client after cataract surgery, as it helps to reduce intraocular pressure and promote drainage and healing of the eye.
Correct Answer is D
Explanation
Choice A Reason: N0 does not indicate presence of regional lymph node involvement, but absence of it. N1 to N3 indicate increasing degrees of regional lymph node involvement.
Choice B Reason: TIS does not indicate that a tumor has been resolved, but that it is in situ, meaning that it is confined to the original site and has not invaded deeper tissues.
Choice C Reason: T4 does not indicate a tumor at its smallest size, but at its largest size. T1 to T4 indicate increasing sizes or extents of the primary tumor.
Choice D Reason: M1 indicates tumor metastasis to a single site, meaning that the cancer has spread to another organ or distant lymph node. M0 indicates no distant metastasis.
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