The nurse is assessing a client who recently returned from surgery for a femur fracture. The client begins to complain of pain, numbness, and tingling to the affected extremity. Upon assessment, the extremity is cold to the touch with no pedal pulse and no motor function. Which of the following actions should the nurse take? (Select all that apply)
Apply a constricting bandage/gauze wrap
Advise the client they will need an immediate amputation
Prepare the client to go back to the operating room
Elevate the extremity and apply ice
Notify the surgeon
Correct Answer : C,E
A. Applying a constricting bandage/gauze wrap is contraindicated. This could further compromise circulation and exacerbate ischemia.
B. Advising the client about an immediate amputation is inappropriate and outside the nurse's scope of practice. The focus should be on timely intervention and notifying the surgeon.
C. Preparing the client to go back to the operating room is appropriate because the symptoms indicate potential compartment syndrome or vascular compromise, which often requires surgical intervention to restore circulation.
D. Elevating the extremity and applying ice is contraindicated in this scenario. Elevation can further decrease blood flow to an already ischemic limb, and ice application can cause vasoconstriction, worsening the issue.
E. Notifying the surgeon is essential. The described symptoms are a surgical emergency requiring immediate evaluation and intervention to prevent permanent damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Avoiding crowds is appropriate, as both Sulfasalazine and Azathioprine can suppress the immune system, increasing the risk of infection.
B. It is correct that it may take several weeks for these medications to show effects, especially with Sulfasalazine. This is a reasonable statement.
C. Notifying the provider if the client experiences fevers is important because it could be a sign of infection, which is a potential side effect of Azathioprine, an immunosuppressive drug.
D. Orange urine is a common side effect of Sulfasalazine and is harmless. The client should not go to the emergency room for this symptom, as it is a known and expected side effect. Therefore, the statement about going to the emergency room indicates a need for further teaching.
Correct Answer is D
Explanation
A. A CT scan of the head is not indicated based on the laboratory findings provided. The priority intervention is related to the elevated potassium level.
B. Chvostek’s sign is associated with hypocalcemia (low calcium levels), not hyperkalemia (high potassium levels).
C. A chest X-ray is not the priority intervention for elevated potassium. The primary concern is the potential for cardiac arrhythmias related to the high potassium level.
D. Hyperkalemia (potassium 6.6 mEq/L) can lead to cardiac arrhythmias. The nurse should obtain a 12-lead ECG to assess for any changes in the heart's electrical activity, which could indicate serious complications like arrhythmias or cardiac arrest.
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