A nurse is assessing a toddler following the casting of the right arm due to a fractured humerus. Which of the following findings should the nurse identify as a manifestation of compartment syndrome?
Heart rate 120/min
Bounding radial pulse
Respiratory rate 28/min
Weak hand grip
The Correct Answer is D
A. Heart rate 120/min: Tachycardia can be a nonspecific response to pain, anxiety, or dehydration in a toddler. While it may accompany compartment syndrome due to pain or hypoperfusion, it is not a definitive early sign of increased compartment pressure.
B. Bounding radial pulse: A bounding pulse indicates strong blood flow and is inconsistent with the compromised circulation seen in compartment syndrome. In this condition, pulses distal to the affected area are often diminished or absent due to increased pressure within the fascial compartment.
C. Respiratory rate 28/min: This respiratory rate is within the normal range for a toddler and is not a reliable indicator of compartment syndrome. Respiratory changes are typically not part of the early clinical manifestations of this localized limb emergency.
D. Weak hand grip: A weak or decreased hand grip is an early sign of neuromuscular compromise associated with compartment syndrome. Increased pressure within the casted compartment can impair circulation and nerve function, leading to motor deficits such as weakness, numbness, or tingling in the affected extremity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A client who has measles: Measles is a highly contagious viral infection transmitted via airborne droplets that can remain suspended in the air for long periods. Implementing airborne precautions, including placing the client in a negative-pressure room and using an N95 or higher-level respirator, is essential to prevent transmission to others.
B. A client who has vancomycin-resistant enterococcus: VRE is transmitted primarily via contact with contaminated surfaces or direct contact with infected persons. Contact precautions, including gloves and gowns, are appropriate, but airborne precautions are not necessary.
C. A client who has pertussis: Pertussis (whooping cough) is transmitted through respiratory droplets, so droplet precautions, including a surgical mask for staff and visitors, are indicated. Airborne precautions are not required.
D. A client who has respiratory syncytial virus: RSV is primarily spread via contact with respiratory secretions and droplets. Contact and droplet precautions are recommended, but airborne precautions are not needed unless an aerosol-generating procedure is being performed.
Correct Answer is B
Explanation
A. Keep the urinary bag at bladder level when ambulating: The urinary drainage bag should always be kept below the level of the bladder to promote gravity drainage and prevent backflow of urine. Keeping it at bladder level increases the risk of urine reflux into the bladder, which can introduce bacteria and lead to infection.
B. Secure the catheter to the client's thigh: Securing the catheter prevents traction and movement at the urethral meatus, which can cause microtrauma and facilitate bacterial entry. Stabilization also maintains a closed drainage system, reducing the risk of catheter-associated urinary tract infections (CAUTIs).
C. Obtain urinary samples by disconnecting the tubing connections: Disconnecting the closed drainage system increases the risk of introducing microorganisms into the system. Urine specimens should be obtained from the designated sampling port using aseptic technique to maintain sterility and reduce infection risk.
D. Loop the tubing so that it is lower than the collection bag: Tubing should be free of dependent loops because these can trap urine and promote bacterial growth. Additionally, positioning tubing lower than the collection bag can lead to backflow, increasing the risk of infection.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
