A client with circumferential full thickness burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take?
Monitor the pulses every 2 hours.
Notify the health care provider.
Elevate both legs above heart level with pillows.
Encourage the patient to flex and extend the toes on both feet.
The Correct Answer is B
A. Monitor the pulses every 2 hours: While frequent monitoring is important, the sudden decrease in pulse strength and numbness indicates possible compartment syndrome, which is an emergency. Simply monitoring without intervention could delay necessary treatment and result in tissue necrosis.
B. Notify the health care provider: Weak distal pulses, numbness, and pain in the toes are signs of impaired circulation due to circumferential burns. Immediate notification is required, as the provider may need to perform a escharotomy or other interventions to restore perfusion and prevent permanent damage.
C. Elevate both legs above heart level with pillows: Elevation can help reduce edema but may further compromise arterial blood flow in the presence of vascular compression from circumferential burns. It is not the priority intervention in this emergency.
D. Encourage the patient to flex and extend the toes on both feet: Active movement may help circulation in mild cases but is insufficient for restoring blood flow when pulses are diminished and numbness is present. This does not address the urgent vascular compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Client with a pulse of 118 beats/min: Mild tachycardia is common postoperatively due to pain, anxiety, or hypovolemia. While it requires monitoring, it is not immediately life-threatening.
B. Client with a blood pressure of 90/50 mm Hg: Hypotension warrants assessment and monitoring, as it may indicate fluid loss or bleeding, but it is less immediately critical than severe respiratory depression.
C. Client with a temperature of 96 F (35.6 C): Mild hypothermia is expected after anesthesia and can be managed with warming measures. It is not an immediate threat to airway or life.
D. Client with a respiratory rate of 6 breaths/min: A respiratory rate this low indicates severe respiratory depression, which can rapidly lead to hypoxia and cardiac arrest. Ensuring airway patency and providing ventilation support takes priority over other vital sign abnormalities.
Correct Answer is C
Explanation
A. "All my friends and neighbors are planning a party for me.": Social gatherings may increase exposure to minor infections, but this does not specifically put the client at high risk for sepsis from wound contamination. Precautions can be taken during social interactions.
B. "I hope I can get my water turned back on when I get home.": Lack of running water could affect hygiene, but the statement does not directly indicate immediate exposure to pathogens or a high-risk activity related to the sternal wound.
C. "I am going to have my daughter scoop the cat litter box.": Cat litter can harbor bacteria such as Toxoplasma and other pathogens. Handling it can directly expose the client’s unhealed sternal wound to infection, significantly increasing the risk of sepsis.
D. "My grandkids are so excited to have me coming home!": Interaction with grandchildren generally poses minimal infection risk if standard hygiene is followed. This does not indicate a direct threat to the healing wound or risk of sepsis.
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