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.
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Related Questions
Correct Answer is D
Explanation
A. Withholding medication for phantom limb pain is inappropriate. Phantom limb pain is a real phenomenon, and it should be managed with appropriate analgesics or other pain management strategies.
B. Keeping the residual limb elevated immediately after surgery is not recommended for prolonged periods as it can lead to contractures. The goal is to avoid excessive flexion at the hip and promote proper positioning.
C. Continuing to use the limb prosthesis when skin is irritated could worsen the irritation and cause skin breakdown. Proper skin care and regular monitoring are essential before using the prosthesis.
D. Laying prone for 30 minutes, 3-4 times a day is an appropriate intervention to prevent hip contractures and encourage proper alignment of the residual limb. This helps to maintain the flexibility of the hip joint and prepares the client for prosthetic fitting.
Correct Answer is A
Explanation
A. A potassium level of 3.3 mEq/L indicates hypokalemia, which can lead to cardiac dysrhythmias due to the role of potassium in maintaining normal cardiac conduction and muscle contraction. Monitoring the client’s heart rhythm is crucial.
B. Neurogenic shock is not a complication of hypokalemia. It is typically caused by spinal cord injury or central nervous system damage, not electrolyte imbalances.
C. Hypoglycemia is not directly associated with hypokalemia or furosemide use. Furosemide primarily affects fluid and electrolyte balance, not glucose regulation.
D. While severe hypokalemia can cause neuromuscular issues, seizures are more commonly associated with conditions like hyponatremia or hypocalcemia, not hypokalemia.
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