A nurse is caring for a client diagnosed with a fractured left tibia and fibula. Which data should the nurse report to the healthcare provider immediately?
Localized edema and discoloration occurring hours after the injury
Pain relieved after taking 4 mg of hydromorphone
Pedal pulses cannot be located with a Doppler and complaints of increasing pain
Generalized weakness and pain at the site of injury
The Correct Answer is C
A. Localized edema and discoloration are expected findings after a fracture and do not typically require immediate reporting unless they are accompanied by signs of compartment syndrome or other complications.
B. Pain relieved by hydromorphone indicates that the pain is being effectively managed. This does not require immediate reporting to the healthcare provider.
C. The absence of pedal pulses, even with the use of a Doppler, combined with increasing pain, is a critical finding that suggests compromised circulation, possibly due to compartment syndrome. This is a medical emergency requiring immediate intervention to prevent permanent tissue damage or loss of the limb.
D. Generalized weakness and pain at the site of injury are common findings after a fracture and do not indicate an urgent complication unless associated with other concerning symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Increasing fluid intake may help with hydration, but it is not the most appropriate intervention for a patient whose peak flow rates are significantly low. The priority is to address the asthma exacerbation.
B. Scheduling a follow-up appointment in two weeks is not appropriate in this situation. The patient is experiencing significant symptoms, and immediate action is required to manage the exacerbation.
C. Advising the patient to avoid all physical activity may not be necessary. Physical activity can be adjusted based on the patient's condition, but the priority is to treat the asthma exacerbation and improve the patient's respiratory status.
D. Initiating an asthma action plan and providing oral corticosteroids is the correct approach. A peak flow rate consistently at 45% of the personal best indicates poor asthma control, and the patient likely requires additional treatment, such as oral corticosteroids, to manage the exacerbation. The asthma action plan should guide further management based on the patient's peak flow rate and symptoms.
Correct Answer is D
Explanation
A. Tidal fluctuation in the water seal chamber is an expected finding in a chest tube drainage system. It indicates that the pleural space is still connected to the atmosphere, and the lungs are expanding and contracting normally.
B. Continuous bubbling in the suction control chamber is normal when the chest tube is connected to suction. This shows that the suction system is functioning properly.
C. Chest tube eyelets not being visible is expected when the chest tube is properly positioned inside the pleural space. This finding does not require immediate notification.
D. Development of subcutaneous emphysema (air trapped under the skin) may indicate an air leak or improper chest tube placement. This finding requires immediate notification of the provider to address the underlying cause and prevent complications.
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