A nurse is assessing for early signs of compartment syndrome for a client who has a short-leg fiberglass cast. Which of the following findings should the nurse expect?
Intense pain with movement
Bounding distal pulses
Erythema of the toes
Capillary refill less than 2 seconds
The Correct Answer is A
Compartment syndrome is a condition in which increased pressure within a confined space compromises blood flow and tissue perfusion, leading to ischemia and necrosis. It can occur after trauma, fracture, or casting of an extremity. The early signs of compartment syndrome include intense pain with movement that is not relieved by analgesics or elevation, paresthesia, pallor, and decreased sensation and motor function of the affected limb. The late signs include absent distal pulses, cyanosis, coldness, and paralysis. Therefore, option A is correct.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Continuous bladder irrigation (CBI) is a procedure that involves instilling sterile fluid into the bladder through a three-way catheter to prevent clot formation and maintain patency after a TURP surgery. The nurse should monitor the client's urine output closely and report any signs of obstruction such as decreased urine flow, blood clots, or abdominal pain.
Correct Answer is C
Explanation
The first action that the nurse should take is to collect information about the irritant that caused the injury, as this will help determine the appropriate treatment and duration of irrigation. Ocular irrigation is the process of flushing the eye with sterile fluid to remove foreign substances or chemicals.
Different types of chemicals may have different effects on the eye, such as acid burns, alkali burns, or organic solvents. Therefore, it is essential to identify the type and concentration of the chemical, as well as the time and duration of the exposure, before proceeding with the irrigation.
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