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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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.

A. Decreased urine output B. Ascending muscle paralysis C. Hypoglycemia D. Ascites

Correct Answer is B

Explanation

A. Decreased urine output is not directly associated with elevated potassium levels. It is more commonly linked to renal failure or dehydration.
B. Hyperkalemia (high potassium levels) can lead to ascending muscle paralysis due to its effects on the neuromuscular system. Potassium is critical for proper muscle function, and elevated levels can disrupt the electrical impulses needed for muscle contraction, potentially causing paralysis.
C. Hypoglycemia is unrelated to elevated potassium levels. It is more often associated with insulin use, inadequate food intake, or certain medical conditions.
D. Ascites is fluid accumulation in the abdomen, usually caused by liver disease or heart failure, and is not a direct complication of hyperkalemia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing laboratory results for a client admitted for renal failure and notes the following: Sodium 144 mEq/L and Potassium 6.6 mEq/L. Which of the following should be the priority intervention?

Correct Answer is D

Explanation

Which of the following is a potential complication for a client whose potassium level is 6.5 mEq/L?

Correct Answer is B

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?

A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?

The nurse is caring for a client who is diabetic and has a blood glucose level of 30 mg/dL. The client is unconscious and has a 20-gauge peripheral IV in the antecubital area. After securing the client's airway, what medication should the nurse plan to administer first?

The nurse is assessing an elderly client admitted for hyponatremia. Which of the following findings requires immediate intervention?

A nurse is preparing to administer 40 mEq of potassium chloride in 45% sodium chloride (NaCl) 500 mL IV to infuse 10 mEq/hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Which of the following interventions should the nurse include when caring for a client who is returning from surgery for an above-the-knee amputation?

You are assessing a client admitted from a long-term care facility. When noting a stage II pressure injury on the client's coccyx, which of the following would you expect?