Four hours following surgical repair of a compound fracture of the right ulna, the nurse is unable to palpate the client’s right radial pulse. Which action should the nurse take first?

Elevate the client’s right hand on one or two pillows.

Measure the client’s blood pressure and apical heart rate.

Complete a neurovascular assessment of the right hand.

Notify the healthcare provider quickly.

Answer and Explanation

The Correct Answer is C

Choice A reason: Elevating the hand reduces edema, potentially improving circulation, but is premature without assessing the absent radial pulse’s cause. Post-fracture, compartment syndrome or arterial injury risks ischemia. Neurovascular assessment identifies severity, guiding targeted interventions to restore perfusion, making elevation secondary to assessment.

Choice B reason: Measuring blood pressure and heart rate provides systemic data but not localized insight into the absent radial pulse, likely from arterial compression post-surgery. Neurovascular assessment evaluates limb perfusion, detecting compartment syndrome or occlusion, critical for urgent intervention to prevent tissue necrosis.

Choice C reason: Completing a neurovascular assessment evaluates pulse, color, warmth, sensation, and movement. Absent radial pulse post-fracture suggests compartment syndrome or arterial injury, risking ischemia. This confirms vascular compromise, guiding interventions like fasciotomy, addressing the pathophysiological threat to limb viability, ensuring timely treatment.

Choice D reason: Notifying the provider follows assessment. Absent radial pulse suggests compartment syndrome, where swelling impairs arterial flow. Neurovascular assessment quantifies severity (e.g., pallor, paresthesia), ensuring accurate reporting for urgent intervention, preventing delays in treating vascular compromise critical to limb preservation.

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Correct Answer is D

Explanation

Choice A reason: Discontinuing the nasal cannula is inappropriate, as 94% SpO₂ indicates mild hypoxemia from pneumonia, requiring oxygen to support alveolar diffusion. The rash likely results from cannula pressure, not oxygen delivery. Padding addresses the rash without compromising respiratory support, ensuring continued therapy.

Choice B reason: Decreasing to 1 L/minute may worsen hypoxemia in pneumonia, where inflamed alveoli impair gas exchange (SpO₂ 94%). The rash is from mechanical irritation, not flow rate. Padding relieves pressure, maintaining oxygen delivery to improve saturation, making flow reduction counterproductive to respiratory needs.

Choice C reason: Applying lubricant reduces friction but not pressure causing the red macular rash from prolonged cannula contact. Lubricants risk aspiration. Padding alleviates pressure points, preventing skin breakdown while maintaining oxygen for pneumonia, addressing the rash’s mechanical cause more effectively than lubrication.

Choice D reason: Placing padding around the cannula tubing relieves pressure on the cheek, preventing skin breakdown from the red macular rash. This maintains oxygen at 3 L/minute, critical for pneumonia’s hypoxemia, where inflamed alveoli reduce oxygen diffusion. Padding ensures skin integrity and respiratory support, addressing both issues effectively.

A. Compare the client’s current vital signs to the admission baseline. B. Review the client’s medical history and admission assessment. C. Note how frequently doses of analgesics have been administered. D. Ask the client to describe the intensity of the pain being experienced.

Correct Answer is D

Explanation

Choice A reason: Comparing vital signs to baseline may show tachycardia from pain-induced sympathetic activation, but this is non-specific, as fever or anxiety can mimic these. Pain is subjective, involving nociceptor signaling, and the client’s direct intensity description provides the most accurate severity measure, guiding targeted treatment.

Choice B reason: Reviewing medical history provides pain context but not current severity. Pain perception involves spinal and cortical nociceptive pathways, and only the client’s description quantifies intensity. Historical data informs diagnosis, but direct assessment is more precise for evaluating present pain, ensuring appropriate analgesic intervention.

Choice C reason: Noting analgesic frequency suggests pain control needs but not current severity. Frequent dosing may indicate tolerance or inadequate relief, not intensity. Pain’s subjective nature, mediated by neural pathways, requires the client’s report to assess severity accurately, guiding dosing over indirect medication usage patterns.

Choice D reason: Asking the client to describe pain intensity directly captures their subjective experience, mediated by nociceptors and cortical perception. Using a 0–10 scale quantifies severity, guiding precise analgesia. This is most effective, as pain is personal, ensuring accurate assessment and tailored treatment to alleviate discomfort effectively.

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Four hours following surgical repair of a compound fracture of the right ulna, the nurse is unable to palpate the client’s right radial pulse. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After obtaining an oxygen saturation level of 94% for a client with pneumonia who is receiving oxygen per nasal cannula at 3 L/minute, the nurse observes a red macular rash developing on the client’s right cheek. Which intervention should the nurse implement?

Correct Answer is D

Explanation

Which nursing intervention is most effective in determining the severity of a client’s pain?

Correct Answer is D

Explanation

A client with gastroesophageal reflux disorder (GERD), who has been self-medicating with famotidine for the past week, is admitted to the acute care center because the symptoms have worsened. The nurse should anticipate which treatment?

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The nurse is assessing a client with a history of heart failure who reports new-onset dyspnea and fatigue. Which finding requires the most immediate intervention?

A client is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular assessment requires immediate intervention by the nurse?

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