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 B
Explanation
A. Assessing blood pressure with a sphygmomanometer is unrelated to Chvostek's sign, which specifically evaluates neuromuscular excitability.
B. Chvostek's sign is assessed by tapping the facial nerve near the cheekbone. A positive response, such as twitching of the facial muscles, indicates hypocalcemia or neuromuscular irritability.
C. Assessing heart rate with a stethoscope does not involve evaluating neuromuscular function or calcium levels.
D. Monitoring respiratory rate with a pulse oximeter is unrelated to Chvostek's sign and does not assess neuromuscular excitability.
Correct Answer is A
Explanation
A. Upper UTI refers to infections that affect the kidneys (pyelonephritis) and ureters. These infections are typically more serious and can lead to kidney damage if not treated promptly.
B. Lower UTI refers to infections that affect the bladder (cystitis) or urethra (urethritis), which are generally less severe than upper UTIs.
C. Urosepsis is a severe, systemic infection that results from a UTI that has spread to the bloodstream. It can occur with either upper or lower UTIs.
D. Uncomplicated UTI refers to a straightforward infection of the urinary tract, typically involving the bladder, in an otherwise healthy individual. It is not specifically related to the kidneys or ureters.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.