Clinical Scenario:

A nurse is assessing a patient who had an external fixation device placed for a tibial fracture 8 hours ago. The patient reports increasing pain that is not relieved by prescribed pain medications. Upon assessment, the nurse notes swelling, a pale and cool foot, and diminished sensation in the toes.

Which of the following assessments should the nurse perform next to further evaluate for compartment syndrome?

Assess for the presence of pedal pulses and capillary refill time.

Measure the patient's calf circumference and compare it bilaterally.

Ask the patient to flex and extend the affected foot to assess for range of motion.

Check for redness and drainage at the pin sites of the external fixation device.

Answer and Explanation

The Correct Answer is A

A. Assess for the presence of pedal pulses and capillary refill time: Compartment syndrome can lead to diminished or absent pulses, delayed capillary refill, and decreased circulation. Assessing pedal pulses and capillary refill is a crucial step in confirming the diagnosis.

B. Measure the patient’s calf circumference and compare it bilaterally: Measuring limb circumference can help assess swelling, but it is not the most critical assessment in this situation. Capillary refill and pedal pulses provide more immediate information about circulation.

C. Ask the patient to flex and extend the affected foot to assess for range of motion: Limited movement can be a sign of compartment syndrome, but if severe pain is already present, further movement may cause more damage. Assessing circulation should be prioritized first.

D. Check for redness and drainage at the pin sites of the external fixation device: Redness and drainage may indicate infection, but this does not directly assess for compartment syndrome. Circulatory assessment is more urgent.

Nursing Test Bank

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Correct Answer is D

Explanation

A. “I should turn my toes inward when lying down.” Internal rotation of the hip increases the risk of dislocation and should be avoided.

B. “I can bend my hip more than 90 degrees when sitting in a chair.” Flexing the hip beyond 90 degrees increases dislocation risk and should be avoided.

C. “I should cross my legs when sitting to improve circulation." Crossing the legs can lead to hip adduction and dislocation. Instead, legs should remain apart.

D. “I should use an abduction pillow between my legs while in bed.” An abduction pillow keeps the legs in proper alignment and prevents dislocation by maintaining slight abduction.

A. Administer antibiotics to the client. B. Teach relaxation breathing to reduce the client's pain. C. Increase the client's protein intake. D. Provide the client with antipyretic therapy.

Correct Answer is A

Explanation

A. Administer antibiotics to the client. Osteomyelitis is a severe bone infection that requires immediate antibiotic therapy to eliminate the infection and prevent complications such as sepsis or bone necrosis.

B. Teach relaxation breathing to reduce the client’s pain. Pain management is important, but it does not address the underlying cause of osteomyelitis. Treating the infection is the priority.

C. Increase the client’s protein intake. A high-protein diet can promote healing, but it does not directly treat the infection and is not the priority intervention.

D. Provide the client with antipyretic therapy. Fever management is beneficial, but treating the underlying infection with antibiotics is more important than simply reducing fever.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following statements by the patient indicates correct understanding of postoperative hip precautions?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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