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 A
Explanation
Choice A rationale
A decreased white blood cell count indicates the body's response to infection is improving, showing the effectiveness of the antibiotics.
Choice B rationale
Increased chest pain and shortness of breath would suggest worsening of the condition, not improvement.
Choice C rationale
Adventitious breath sounds and increased cough are signs that pneumonia may be persisting or worsening.
Choice D rationale
Improved appetite and weight gain are positive signs but are not direct indicators of the effectiveness of antibiotic treatment.
Correct Answer is A
Explanation
Choice A rationale
Alcoholism is a common cause of hypomagnesemia due to poor dietary intake, increased renal excretion, and gastrointestinal losses. Chronic alcohol consumption leads to malnutrition and loss of magnesium through the urine, contributing to low magnesium levels.
Choice B rationale
Dehydration typically leads to hemoconcentration, which can elevate, rather than decrease, magnesium levels. Thus, it is not usually associated with low magnesium levels.
Choice C rationale
Kidney failure generally causes hypermagnesemia, not hypomagnesemia, because the kidneys cannot efficiently excrete magnesium, leading to its accumulation in the blood.
Choice D rationale
Excessive magnesium intake would result in hypermagnesemia, not hypomagnesemia, as the body accumulates more magnesium than it can excrete.
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