A male client is admitted with a comminuted fracture of the femur following a motor vehicle collision. Skeletal traction is applied to maintain alignment and reduce muscle spasms. Eight hours after traction is initiated, the nurse assesses the client and notes the following:
• Complaints of severe leg pain despite IV morphine
• Toes are cool to the touch
• Foot is positioned at the end of the bed
• Pin sites show no drainage
What is the nurse’s priority action?
Reposition the client to improve alignment.
Elevate the foot of the bed to bring the limb closer.
Notify the healthcare provider—signs of neurovascular compromise.
Administer a higher dose of pain medication.
The Correct Answer is C
Choice A reason: Repositioning may help with comfort or alignment but does not address the signs of neurovascular compromise. It is not the priority when critical symptoms are present.
Choice B reason: Elevating the foot of the bed may improve circulation but is not sufficient or appropriate when signs of compartment syndrome or ischemia are suspected. It delays definitive action.
Choice C reason: Severe pain unrelieved by opioids and cool extremities are hallmark signs of neurovascular compromise, possibly compartment syndrome. Immediate notification of the provider is essential to prevent permanent damage or limb loss.
Choice D reason: Administering more pain medication may mask symptoms and delay diagnosis. It does not address the underlying cause and could worsen the situation if neurovascular compromise is present.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Furosemide is a loop diuretic that increases the excretion of sodium, potassium, and water. It is more commonly associated with hypokalemia and hyponatremia, not hyperkalemia.
Choice B reason: Hydrochlorothiazide is a thiazide diuretic that can cause hyponatremia and hypokalemia due to its action on the distal tubule, but it does not typically cause hyperkalemia.
Choice C reason: Spironolactone is a potassium-sparing diuretic that blocks aldosterone, leading to sodium excretion and potassium retention. This mechanism increases the risk of hyperkalemia. Additionally, it can contribute to hyponatremia due to water retention and sodium loss.
Choice D reason: Bumetanide, like furosemide, is a loop diuretic and is associated with hypokalemia and hyponatremia, not hyperkalemia.
Correct Answer is B
Explanation
Choice A reason: A bounding pulse may indicate increased circulation, but it is not typically a red flag unless accompanied by other symptoms. It does not require immediate reporting.
Choice B reason: Unrelieved pain despite analgesics is a hallmark sign of compartment syndrome, a medical emergency. It indicates increased pressure within the cast that can compromise circulation and nerve function.
Choice C reason: Finger stiffness may occur due to immobilization but is not an urgent concern unless accompanied by numbness, pallor, or pain.
Choice D reason: A small amount of bloody drainage may be expected initially. However, excessive or foul-smelling drainage would warrant concern. In this case, the amount described does not require immediate action.
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