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A nurse is assisting in the care of a client who is in the emergency department (ED) following a ski accident.

Exhibits

The nurse is collecting data on the client. Which of the following findings require follow up?

Select all that apply.

Findings of right lower extremity assessment

Pain level

Level of consciousness

Oxygen saturation

Right pedal pulses

Temperature

X-ray results

Answer and Explanation

Correct Answer : A,B,E

A. Findings of right lower extremity assessment: The diminished pulses, cool temperature, and reduced sensation of the right foot suggest impaired circulation and potential compartment syndrome, which is an emergency.
B. Pain level: A pain level of 10/10 that is disproportionate to the injury indicates a need for immediate evaluation, as it may signal compartment syndrome.
C. Level of consciousness: Not concerning as the client is alert and denies loss of consciousness.
D. Oxygen saturation: Normal at 97%.
E. Right pedal pulses: A diminished pedal pulse (1+) on the right is a critical finding that requires urgent intervention to restore circulation.
F. Temperature: A temperature of 36°C is within normal limits and does not require follow-up.
G. X-ray results: Confirms the fracture but is not a finding requiring immediate follow-up compared to circulatory concerns.

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Correct Answer is C

Explanation

A. Keeping both arms below the level of the client's heart is not recommended for preventing lymphedema. The affected arm should be elevated when possible to reduce the risk of fluid accumulation.
B. Obtaining blood pressure readings on the affected arm is contraindicated because it can increase the risk of lymphedema.
C. Use the client's left arm to obtain blood samples: To prevent lymphedema, it's important to avoid using the affected arm (the right arm in this case) for invasive procedures like blood draws or blood pressure measurements, as this can increase the risk of lymphedema by promoting fluid retention.
D. Limiting range-of-motion exercises could impair recovery and muscle function. Early and gentle exercises should be encouraged to maintain mobility and avoid complications.

A. Perform suctioning. B. Instill saline into the tubing. C. Increase the humidification. D. Check the cuff pressure.

Correct Answer is A

Explanation

A. Perform suctioning: Restlessness and crackles in the lungs may indicate retained secretions. Suctioning the tracheostomy can help clear secretions and improve oxygenation.
B. Instill saline into the tubing: Routine instillation of saline is not recommended as it can cause discomfort, dislodge bacteria, or create a risk of aspiration.
C. Increase the humidification: While humidification helps prevent mucus from becoming thick, it does not address the immediate issue of retained secretions causing crackles.
D. Check the cuff pressure: While it is important to ensure appropriate cuff pressure, this is not the primary intervention for resolving restlessness and crackles, which suggest secretion buildup.

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A nurse is assisting in the care of a client who is in the emergency department (ED) following a ski accident. Exhibits The nurse is collecting data on the client. Which of the following findings require follow up? Select all that apply.

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Correct Answer is C

Explanation

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A nurse is assisting in the care of a client who is in the emergency department (ED) following a ski accident.

Exhibits

The nurse is collecting data on the client. Which of the following findings require follow up?

Select all that apply.