A nurse is assessing a client who is 24 hours postoperative following an open reduction and internal fixation to repair a fracture of the femur. Which of the following assessment findings is an early manifestation of fat embolism syndrome (FES)?
Headache
Dyspnea
Red-brown petechiae
Altered mental status
The Correct Answer is B
Choice A reason: Headache can be associated with FES; however, it is not typically considered an early sign. It may occur as a part of the broader spectrum of symptoms.
Choice B reason: Dyspnea, or difficulty breathing, is one of the earliest signs of FES. Patients may experience shortness of breath due to fat globules obstructing pulmonary vessels.
Choice C reason: Red-brown petechiae, which are small, pinpoint hemorrhages, can appear on the skin and are a classic sign of FES, often found in the axillary region or on the chest.
Choice D reason: Altered mental status, including confusion and drowsiness, can occur early in FES due to fat emboli traveling to the cerebral circulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Physical therapy may be prescribed postoperatively to aid in recovery, but it does not directly interfere with the function of a pacemaker.
Choice B reason: Checking serum cardiac enzyme levels is a common practice after heart surgery to assess for any damage to the heart muscle, which would not typically require clarification in the context of pacemaker insertion.
Choice C reason: An MRI of the chest should be clarified with the healthcare provider because MRI can interfere with pacemaker function. Patients with pacemakers are generally advised to avoid MRI unless the pacemaker is Incompatible, due to the risk of the magnetic field affecting the device's operation.
Choice D reason: A low sodium diet may be recommended for patients with heart conditions to manage blood pressure and fluid retention, but it is not directly related to the care of a pacemaker.
Correct Answer is C
Explanation
Choice A: Sleepy, but arousing when the name is called
Feeling sleepy after receiving morphine is a common side effect. However, the fact that the client can be aroused when their name is called suggests that this is not necessarily an adverse effect.
The nurse should continue monitoring the client but may not consider this as a significant adverse reaction.
Choice B: Pain level of 6 on a scale from 0 to 10
Pain relief is one of the intended effects of morphine. Therefore, experiencing pain reduction is not an adverse effect.
The nurse would likely view this as a positive response to the medication.
Choice C: Respiratory rate of 8/min
A respiratory rate of 8 breaths per minute is significantly low and indicates respiratory depression, which is a serious adverse effect of morphine.
The nurse should be concerned about this finding and take appropriate action.
Choice D: SaO2 94%
An oxygen saturation (SaO2) level of 94% is within the normal range (usually 95% or higher). It is unlikely to be directly related to morphine administration.
While this value is not concerning, the nurse should continue monitoring the client's oxygen saturation.
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