A nurse in an emergency department is caring for a 60-year-old client.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

1. Condition: Acute Compartment Syndrome

Justification: The presence of severe pain, swelling, numbness, and a weak radial pulse along with delayed capillary refill are classic signs of acute compartment syndrome. Immediate surgical intervention (fasciotomy) is necessary to relieve the pressure within the muscle compartments.

2. Actions to Take

Prepare for Fasciotomy:

Justification: This surgical procedure will relieve the internal pressure causing the symptoms.

Request Prescription for Pain Medication:

Justification: Adequate pain management is important for client comfort and can also indicate response to treatment.

3. Parameters to Monitor

Neurovascular Status:

Justification: Monitoring for further deterioration of symptoms such as worsening numbness or weak pulses is essential.

WBC Count:

Justification: Helps in the broader assessment of possible infection, though not directly related to acute compartment syndrome

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Correct Answer is C

Explanation

A. The side-lying position is not appropriate for paracentesis because it does not allow optimal access to the abdomen and can make fluid removal more difficult.

B. The supine position is also not suitable for paracentesis, as it may not allow for proper drainage and can increase the risk of respiratory compromise, especially in clients with large volumes of ascitic fluid.

C. High-Fowler’s position is correct because it helps pool the ascitic fluid in the lower abdomen, making it easier to access and drain during the procedure. This position also helps improve breathing by relieving pressure on the diaphragm caused by the ascites.

D. The leaning forward position is not appropriate for paracentesis, as it can be uncomfortable and does not provide optimal access to the abdominal cavity for fluid removal.

A. Obtain a cardiology consult. B. Perform pre-oxygenation prior to suctioning. C. Administer an antidysrhythmic medication. D. Suction the client less frequently.

Correct Answer is B

Explanation

A. Obtain a cardiology consult is not an immediate action for an irregular heart rate during suctioning; it is a more long-term consideration.

B. Perform pre-oxygenation prior to suctioning is the correct action to prevent hypoxia, which can cause increased heart rate and irregular rhythms during suctioning.

C. Administer an antidysrhythmic medication is not appropriate for the immediate concern of heart rate changes during suctioning.

D. Suction the client less frequently does not address the acute problem of the irregular heart rate; pre-oxygenation before suctioning is more relevant.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a client who is scheduled to undergo a paracentesis. Into which of the following positions should the nurse assist the client for this procedure?

Correct Answer is C

Explanation

A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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