A nurse is assisting in the care of the client who is postoperative following a fasciotomy.

Exhibits

Which of the following actions should the nurse take? Select all that apply.

Prepare to obtain a wound culture.

Restrict fluid intake.

Administer an analgesic

Prepare to administer an antibiotic

Initiate supplemental oxygen.

Answer and Explanation

Correct Answer : A,C,D

A. Prepare to obtain a wound culture: A culture is necessary if infection is suspected.
B. Restrict fluid intake: Contraindicated as hydration is important to support healing and kidney function.
C. Administer an analgesic: Pain management is crucial postoperatively.
D. Prepare to administer an antibiotic: Antibiotics are indicated for infection prophylaxis or treatment.
E. Initiate supplemental oxygen: Not needed unless signs of respiratory distress or hypoxia are present.

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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.

A. Findings of right lower extremity assessment B. Pain level C. Level of consciousness D. Oxygen saturation E. Right pedal pulses F. Temperature G. X-ray results

Correct Answer is ["A","B","E"]

Explanation

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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A nurse is assisting in the care of the client who is postoperative following a fasciotomy. Exhibits Which of the following actions should the nurse take? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Explanation

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A nurse is assisting in the care of the client who is postoperative following a fasciotomy.

Exhibits

Which of the following actions should the nurse take? Select all that apply.