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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Skip lesions and a cobblestone appearance are characteristic of Crohn's disease, not ulcerative colitis (UC). UC involves continuous inflammation of the colon, without skip lesions.
B. Ulcerative colitis is associated with a risk for bowel perforation and toxic megacolon, which are serious complications of the disease.
C. Diarrhea containing blood is a common symptom of ulcerative colitis, as it primarily affects the colon and rectum, leading to inflammation and ulceration.
D. Increased risk for colorectal cancer is a known complication of ulcerative colitis, especially with long-term disease duration.

A. Antihypertensive medication B. Fluid replacement C. Potassium laboratory monitoring D. Insulin IV infusion

Correct Answer is A

Explanation

A. Antihypertensive medication is not a priority intervention for a client with a blood glucose level of 620 mg/dL, which indicates hyperglycemia, likely due to diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS). The focus should be on correcting the hyperglycemia and preventing complications like dehydration or electrolyte imbalances.
B. Fluid replacement is essential to treat dehydration caused by hyperglycemia, as high blood glucose levels cause osmotic diuresis.
C. Potassium laboratory monitoring is crucial because insulin treatment can shift potassium into cells, potentially causing hypokalemia, so monitoring is necessary during treatment.
D. Insulin IV infusion is necessary to lower the blood glucose level in clients with severe hyperglycemia, such as in DKA or HHS.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse knows that all of the following are features of ulcerative colitis (UC) except which?

Correct Answer is A

Explanation

The nurse is caring for a client with a blood glucose reading of 620 mg/dL. The nurse would expect all of the following interventions except which?

Correct Answer is A

Explanation

A client who is recovering from a lower extremity amputation complains of tingling and "shooting" pain in the amputated extremity. The nurse knows that which of the following is true about this type of pain?

The nurse is caring for a client who was admitted for a closed femur fracture. Which of the following signs and symptoms would alert the nurse that the client is experiencing compartment syndrome?

A nurse is monitoring a client receiving an infusion of IV magnesium sulfate. Which of the following findings would indicate to the nurse that the client is experiencing hypermagnesemia?

The nurse is caring for a pediatric client who experienced a "greenstick" fracture. The client's mother asks the nurse what it means to have this type of fracture. Which of the following statements should the nurse make?

A nurse is assessing a client who has a sodium level of 116 mEq/L. Which of the following adverse findings would the nurse anticipate?

A patient presents with a heart rate of 130 beats/minute and a blood pressure of 82/66 after exerting themselves in the sun. Which of the following interventions would be most appropriate?

The nurse is caring for a client who is admitted with acute dehydration and a serum sodium level of 151mEq/L. The nurse is anticipating the administration of DSW based on which of the following principles?

A nurse is finalizing preparations for a patient going to surgery in 30 minutes. Which of the following tasks should be the nurse's top priority?