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 C

Explanation

A. Ascending muscle weakness is more characteristic of hypokalemia (low potassium levels) rather than hypernatremia.
B. Muscle tetany and hyperreflexia are typically seen in hypocalcemia (low calcium levels) or hypomagnesemia (low magnesium levels), not hypernatremia.
C. Hypernatremia (high sodium levels) commonly causes dehydration, which results in poor skin turgor and dry mucous membranes. This is a key clinical sign of hypernatremia.
D. Bradycardia and hypotension are more commonly associated with hypovolemia (low blood volume) or hypotension, but they are not specific to hypernatremia.

A. Hypertension and headache B. Tachycardia and tachypnea C. Depressed deep tendon reflexes D. Positive Trousseau's sign

Correct Answer is C

Explanation

A. Hypertension and headache are not typical signs of hypermagnesemia. These symptoms are more commonly associated with conditions like hypertension or intracranial pressure.
B. Tachycardia and tachypnea are not characteristic of hypermagnesemia. In fact, hypermagnesemia typically causes bradycardia and hypoventilation due to the depressant effect of magnesium on the cardiovascular and respiratory systems.
C. Depressed deep tendon reflexes are a classic sign of hypermagnesemia. Magnesium sulfate acts as a central nervous system depressant, and elevated magnesium levels can impair neuromuscular function, leading to reduced reflexes.
D. Positive Trousseau's sign is indicative of hypocalcemia, not hypermagnesemia. It is a sign of low calcium levels, where a blood pressure cuff inflated above systolic pressure for 3 minutes causes muscle spasms in the hand and forearm.

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Naxlex Comprehensive Predictor Exams

Which assessment finding is most indicative of hypernatremia?

Correct Answer is C

Explanation

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?

Correct Answer is C

Explanation

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?

Which of the following signs and symptoms from a client who came to the clinic for an exacerbation of Crohn's Disease is the most concerning?

A client presents to the emergency department with complaints of urinary frequency, dysuria, and fever. Which of the following orders should the nurse carry out first?

A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?

The nurse is providing education to a client newly diagnosed with gastroesophageal reflux disease (GERD). The nurse knows that the teaching was effective when the client states they should eat which of the following foods?

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?

The nurse should explain that which of the following medications puts a client at risk for developing hyperkalemia?

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?