A nurse is assisting with the care of a client.
Exhibits
The nurse is caring for a client who has a hip and pelvis fracture. Select the 4 findings on Day 2 that require immediate follow-up.
Heart rate
Oxygen saturation
Edema
Temperature
Urine color
Pedal pulses
Correct Answer : A,C,E,F
Heart rate: The increase in heart rate from 92/min to 108/min suggests possible complications such as pain, infection, or hypovolemia.
Oxygen saturation: it is within normal range (96%), it doesn’t indicate an immediate problem.
Edema: Increased edema from slight to 2+ suggests worsening of the condition, possibly indicating an underlying issue such as poor circulation or developing compartment syndrome.
Temperature: The slight increase in temperature is not immediately concerning.
rine color: Dark, reddish-brown urine is concerning for possible rhabdomyolysis or other renal issues.
Pedal pulses: Diminished pedal pulses (from +2 to +1) and prolonged capillary refill time (6 seconds) indicate compromised peripheral circulation, which needs immediate attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Providing a caring and supportive attitude during a challenging time: While emotional support is crucial and beneficial for the patient's overall well-being and recovery, it is not the primary focus when dealing with external fixation and the risk of complications.
B. Monitoring pin and wound sites for signs of infection: Infection is a significant risk with external fixation devices, and early detection is critical to prevent severe complications such as osteomyelitis. This makes monitoring for infection the most important focus.
C. Being aware that the patient may experience issues with body image: Body image concerns are valid and can affect a patient’s mental health, but they are secondary to the physical risks associated with external fixation, such as infection.
D. Helping the patient achieve a desired level of mobility: Mobility is an important goal in the patient's rehabilitation, but ensuring the prevention of infection takes precedence because an infection can severely impact overall recovery.
Correct Answer is D
Explanation
A. Poor circulation: Poor circulation would manifest as coolness, pallor, or decreased pulses distal to the cast, not warmth or odor.
B. Uneven cast drying: Uneven cast drying might cause discomfort or improper immobilization, but it typically does not cause warmth or odor.
C. Pressure from the cast: Pressure from the cast could cause pressure sores, which might lead to infection, but the primary issue here seems to be the signs of infection directly.
D. Infection: Warmth and odor from the cast are indicative of an underlying infection, which is a significant complication requiring prompt attention.
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