A nurse is collecting data from a client who has a fractured left femur and is in skeletal traction. Which of the following findings should the nurse identify as an indication of fat emboli to report to the provider?
Ecchymosis of the thigh
Serous drainage at the pin site
Chest petechiae
Muscle spasms in the left leg
The Correct Answer is C
Choice A reason: This is an incorrect finding, because ecchymosis of the thigh, or bruising, is not a sign of fat emboli, but a sign of bleeding or hematoma formation due to the fracture or the traction. The nurse should monitor the size and color of the ecchymosis and report any changes to the provider.
Choice B reason: This is an incorrect finding, because serous drainage at the pin site, or clear fluid, is not a sign of fat emboli, but a sign of normal healing or infection. The nurse should assess the amount, color, and odor of the drainage and report any signs of infection, such as purulent drainage, redness, swelling, or pain, to the provider.
Choice C reason: This is the correct finding, because chest petechiae, or small red spots on the chest, are a sign of fat emboli, which are a rare but serious complication of long bone fractures. Fat emboli occur when fat globules from the bone marrow enter the bloodstream and travel to the lungs, causing respiratory distress, hypoxia, and pulmonary edema. The nurse should report any signs of fat emboli, such as chest petechiae, dyspnea, tachypnea, tachycardia, fever, or confusion, to the provider.
Choice D reason: This is an incorrect finding, because muscle spasms in the left leg, or involuntary contractions of the muscles, are not a sign of fat emboli, but a sign of pain, inflammation, or nerve injury due to the fracture or the traction. The nurse should administer analgesics and muscle relaxants as prescribed, and provide comfort measures, such as massage, ice, or elevation, to the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct imbalance, because respiratory alkalosis is a condition that occurs when the blood pH is high, the PaCO2 is low, and the HCO3 is normal or low. Respiratory alkalosis is caused by hyperventilation, which can result from anxiety, fever, pain, or mechanical ventilation.
Choice B reason: This is an incorrect imbalance, because metabolic acidosis is a condition that occurs when the blood pH is low, the PaCO2 is normal or low, and the HCO3 is low. Metabolic acidosis is caused by the accumulation of acids in the blood, which can result from diabetic ketoacidosis, renal failure, or lactic acidosis.
Choice C reason: This is an incorrect imbalance, because respiratory acidosis is a condition that occurs when the blood pH is low, the PaCO2 is high, and the HCO3 is normal or high. Respiratory acidosis is caused by hypoventilation, which can result from airway obstruction, chest injury, or narcotic overdose.
Choice D reason: This is an incorrect imbalance, because metabolic alkalosis is a condition that occurs when the blood pH is high, the PaCO2 is normal or high, and the HCO3 is high. Metabolic alkalosis is caused by the loss of acids from the blood, which can result from vomiting, gastric suction, or diuretic therapy.
Correct Answer is B
Explanation
Choice A reason: This is an incorrect finding, because Kussmaul respirations are a sign of diabetic ketoacidosis (DKA), which is a complication of type 1 diabetes mellitus that occurs when the blood glucose is too high, not too low. Kussmaul respirations are deep and rapid breathing that help the body eliminate excess carbon dioxide and acid.
Choice B reason: This is the correct finding, because diaphoresis is a sign of hypoglycemia, which is a condition that occurs when the blood glucose is too low. Diaphoresis is excessive sweating that results from the activation of the sympathetic nervous system and the release of epinephrine, which stimulate the body to increase the blood glucose level.
Choice C reason: This is an incorrect finding, because decreased skin turgor is a sign of dehydration, which is a complication of type 1 diabetes mellitus that occurs when the blood glucose is too high, not too low. Decreased skin turgor is a loss of elasticity and firmness of the skin that results from the loss of fluid and electrolytes through the urine and the skin.
Choice D reason: This is an incorrect finding, because ketonuria is a sign of diabetic ketoacidosis (DKA), which is a complication of type 1 diabetes mellitus that occurs when the blood glucose is too high, not too low. Ketonuria is the presence of ketones in the urine, which are acidic substances that are produced when the body breaks down fat for energy due to the lack of insulin.
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