A client with a right ulnar fracture and cast placement reports an increase in arm pain. Which action should the nurse take next?

Implement distraction techniques.

Assess right radial pulse volume.

Administer a PRN analgesic.

Measure the blood pressure.

Answer and Explanation

The Correct Answer is B

B. An increase in pain after cast placement could indicate complications such as compartment syndrome, which is a serious condition that occurs when increased pressure within a confined space (such as the area within the cast) compromises circulation and tissue perfusion. Assessing the radial pulse volume on the affected arm is crucial to evaluate perfusion distal to the fracture site.
A. Distraction technique may help manage the client's pain but does not address the underlying cause of the pain increase, which could be related to compromised circulation.
C. Analgesics relieve pain but do not address the immediate limb threatening issue at hand.
D. Measuring blood pressure is not directly related to assessing circulation distal to the fracture site.

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Correct Answer is A

Explanation

Left ventricular dysfunction leads to inadequate stroke volume and cardiac output to the systemic circulation. This leads to fatigue and exertional dyspnea.
B. Lower extremity is a typical finding in right ventricular dysfunction. Inadequate pumping in the right ventricular leads to volume overload in the systemic circulation.
C. Hepatomegaly is a typical finding in right ventricular dysfunction
D. Jugular vein dysfunction is a typical finding in right ventricular dysfunction.

A. Observe for prolonged periods of apnea. B. Observe for lacerations to the tongue. C. Document details of the seizure activity. D. Evaluate for evidence of incontinence.

Correct Answer is A

Explanation

A. This intervention is important for assessing the client's respiratory status during and after the seizure. Apnea can cause cardiac arrest and respiratory failure and hence a priority.
B. This intervention is crucial for assessing potential injury to the client's mouth or tongue, which can occur during a seizure due to involuntary muscle movements. However, before assessing for lacerations, the nurse should prioritize ensuring the client's safety.
C. Documenting details of the seizure activity is important for maintaining accurate medical records and providing information to the healthcare team. However, before documenting details of the seizure, the nurse should prioritize ensuring the client's safety and providing immediate assistance during the seizure. Therefore, while documentation is essential, it may not be the first intervention to implement.
D. While evaluating for incontinence is important for addressing the client's immediate needs and ensuring comfort, it may not be the first intervention to implement. The nurse should prioritize ensuring the client's safety and providing immediate assistance during the seizure.

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A client with a right ulnar fracture and cast placement reports an increase in arm pain. Which action should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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