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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Clients receiving thrombolytic therapy are at an increased risk of bleeding, which can manifest as internal bleeding, hemorrhage at vascular access sites, gastrointestinal bleeding, or intracranial bleeding. The nurse's priority is to closely monitor the client for signs and symptoms of bleeding, such as sudden onset or worsening of headache, changes in level of consciousness, hematuria, melena, ecchymosis, or hematoma formation.
B. While activity intolerance is a common nursing diagnosis for clients following an acute myocardial infarction due to myocardial ischemia, it is not the priority in this case where the client is actively receiving thrombolytic therapy.
C. While respiratory complications can occur following thrombolytic therapy, such as pulmonary embolism or bleeding into the lungs, the risk of bleeding complications takes precedence as the priority nursing problem for this client.
D. Education about the new medication regimen is important for client understanding and adherence, but it is not the priority nursing problem in the immediate post-thrombolytic therapy period.
Correct Answer is B
Explanation
B. Acute pancreatitis is inflammation of the pancreas that can cause severe upper abdominal pain, which may radiate to the back, fever, and vomiting. Elevated serum amylase and lipase levels are characteristic laboratory findings in acute pancreatitis, indicating pancreatic injury or inflammation. The client's symptoms and laboratory results are consistent with acute pancreatitis.
A. Hepatorenal failure, also known as hepatorenal syndrome, is a serious complication of advanced liver disease where there is progressive renal failure in the setting of liver dysfunction. While hepatorenal syndrome can present with symptoms such as abdominal pain, fever, and vomiting, it is not typically associated with significantly elevated serum amylase and lipase levels.
C. Biliary duct obstruction occurs when there is a blockage in the bile ducts, leading to impaired flow of bile from the liver to the small intestine. While biliary duct obstruction can cause symptoms such as upper abdominal pain and vomiting, it is not typically associated with significantly elevated serum amylase and lipase levels.
D. While surgical site infection is a potential complication following cholecystectomy (gallbladder removal surgery), it typically presents with symptoms such as wound redness, swelling, warmth, and purulent drainage from the incision site.
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