A nurse is caring for a client in an orthopedic unit.

Exhibits

Drag words from the choices below to fill in each blank in the following sentence.

The client is at risk for developing
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and
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Answer and Explanation

The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}

Deep vein syndrome: This is not a recognized condition. The intended term may have been deep vein thrombosis (DVT), which is a valid orthopedic complication, but the clinical findings in this scenario point more urgently toward compartment syndrome and infection.
Osteomyelitis: The client has an open fracture with drainage from the splint, a significantly elevated WBC count (28,000/mm³), and a high fever (38.9°C / 102°F). These findings suggest the development of a bone infection (osteomyelitis), especially in the context of recent surgery and internal fixation.
Fat embolism syndrome: While fat embolism is a risk with long bone fractures, this client is not displaying key hallmark signs such as respiratory distress, petechiae, or altered mental status. The findings are more consistent with infection and circulatory compromise.
Compartment syndrome: The client has classic signs including cool foot, numbness, inability to move toes, absent pulses, delayed capillary refill, and increased pain. These are hallmark signs of neurovascular compromise from compartment syndrome, a surgical emergency.

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Correct Answer is A

Explanation

A. Assess the client's peripheral pulses every 15 min. Frequent assessment of peripheral pulses, especially in the affected extremity, is essential to monitor for signs of arterial occlusion, hematoma, or compromised circulation following a femoral catheterization.

B. Change the client's dressing 4 hr following the procedure. The initial pressure dressing should not be disturbed unless there are signs of bleeding or saturation. Routine dressing changes this soon can disrupt the clotting process at the insertion site.

C. Instruct the client to flex the right knee every 30 min. The client should keep the affected leg straight to prevent disrupting the insertion site. Flexing the knee can increase the risk of bleeding and compromise the integrity of the puncture site.

D. Elevate the head of the client's bed to 45°. Elevating the head of the bed too high can increase abdominal pressure on the femoral site, risking bleeding. The bed should be kept no higher than 30° to reduce stress on the insertion area.

A. Provide a verbal report of the client's condition to the paramedic performing the transfer. B. Email the client's health information to the facility in an unencrypted file. C. Discuss the client's response to the transfer with another staff nurse. D. Fax the client's name and identifiable information to the rehabilitation facility

Correct Answer is A

Explanation

A. Provide a verbal report of the client's condition to the paramedic performing the transfer. This is an appropriate and secure method for communicating essential health information directly involved in the client’s care. It ensures continuity of care while maintaining confidentiality.
B. Email the client's health information to the facility in an unencrypted file. Sending health information via unencrypted email violates HIPAA guidelines and poses a risk to client confidentiality due to potential unauthorized access.
C. Discuss the client's response to the transfer with another staff nurse. Unless the staff nurse is directly involved in the client’s care, this would be a breach of confidentiality. Personal health information should only be shared on a need-to-know basis.
D. Fax the client's name and identifiable information to the rehabilitation facility. Faxing is permissible only when appropriate safeguards are in place. However, faxing identifiable information without confirming the recipient or using secure protocols can risk a confidentiality breach.

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A nurse is caring for a client in an orthopedic unit. Exhibits Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing dropdownanddropdown

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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A nurse is caring for a client in an orthopedic unit.

Exhibits

Drag words from the choices below to fill in each blank in the following sentence.

The client is at risk for developing
dropdown
and
dropdown