A patient who had open reduction and internal fixation (ORIF) of left lower leg fractures continues to report severe pain in the leg 15 minutes after receiving the prescribed IV morphine.
The nurse determines pulses are faintly palpable and the foot is cool to the touch.
Which action should the nurse take next?
Check the patient's blood pressure.
Notify the health care provider.
Assess the incision for redness.
Reposition the left leg on a pillow.
The Correct Answer is B
Choice A rationale
Checking the blood pressure is not the priority action in this case. The symptoms described may suggest compartment syndrome, which is a medical emergency and requires immediate intervention.
Choice B rationale
The correct action is to notify the health care provider immediately as this may indicate compartment syndrome, a serious complication that can occur after fractures and can lead to permanent damage if not treated promptly.
Choice C rationale
Assessing the incision for redness is not appropriate in this scenario as the symptoms suggest a more severe underlying issue such as compartment syndrome, which requires urgent attention.
Choice D rationale
Repositioning the leg may provide temporary relief but does not address the potential underlying issue of compartment syndrome. The priority is to notify the health care provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E"]
Explanation
Choice D rationale
Administering aspirin 325 orally is important for clients with a myocardial infarction (MI). Aspirin helps to inhibit platelet aggregation, reducing the risk of further clot formation and improving blood flow to the heart. This can significantly decrease mortality and complications associated with MI.
Choice E rationale
Applying oxygen via nasal cannula helps to increase oxygen delivery to the heart and other vital organs during an MI. Ensuring adequate oxygenation can help reduce the extent of myocardial injury and support overall cardiac function during a critical period.
Choice A rationale
Placing the client in a supine position is not appropriate during an MI, as it can increase discomfort and the workload on the heart. Instead, the client should be positioned in a semi-Fowler’s or comfortable position to improve breathing and comfort.
Choice B rationale
Administering morphine intramuscularly is not recommended during an MI. Morphine can be used for pain relief but should be given intravenously to ensure rapid onset and better control over dosing. Intramuscular administration is less effective and can delay pain relief.
Choice C rationale
Administering nitroglycerin subcutaneously is not appropriate. Nitroglycerin is typically given sublingually or intravenously during an MI to provide rapid vasodilation and pain relief. Subcutaneous administration is not effective in this context. .
Correct Answer is C
Explanation
Choice A rationale
Intestinal malabsorption syndrome is not typically associated with ulcerative colitis or anemia caused by this condition. Malabsorption is more often related to other gastrointestinal conditions.
Choice B rationale
Intestinal parasites are not a common cause of anemia in individuals with ulcerative colitis. The chronic inflammation and blood loss are more likely contributors.
Choice C rationale
Chronic blood loss from the intestinal lining due to ulcerative colitis is a major contributing factor to anemia. The ongoing inflammation and ulceration can cause significant blood loss over time.
Choice D rationale
Dietary iron restrictions are not typically associated with ulcerative colitis. Anemia in this context is more likely due to chronic blood loss rather than dietary deficiencies.
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