The nurse is caring for a client diagnosed with a fractured tibia and fibula.Which data should the nurse report to the healthcare provider immediately?
Dorsalis pedis pulse cannot be located with a doppler and increasing pain.
Pain relieved after administering 4 mgs of hydromorphone.
Generalized weakness and increasing sensitivity to touch.
Localized edema and discoloration of the affected limb.
The Correct Answer is A
Choice A rationale
Inability to locate the dorsalis pedis pulse and increasing pain are signs of compromised circulation, requiring immediate intervention.
Choice B rationale
Pain relieved by medication does not indicate an urgent situation and suggests effective pain management.
Choice C rationale
Generalized weakness and increased sensitivity to touch are not typically indicative of a critical emergency requiring immediate reporting.
Choice D rationale
Localized edema and discoloration are expected findings following a fracture and do not necessitate immediate reporting.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale
Preparing the client for lithotripsy is important for treatment but is not the immediate highest priority in an emergency setting. Immediate pain management takes precedence.
Choice B rationale
Ordering a renal ultrasound is necessary for assessing the stones but comes after stabilizing the client's acute symptoms, including managing pain.
Choice C rationale
Administering pain medication as prescribed is the highest priority because renal colic causes severe pain. Immediate pain relief is crucial for the client's comfort and to facilitate further diagnostic and therapeutic interventions.
Choice D rationale
Initiating IV fluid therapy is important for hydration and possibly aiding stone passage but follows after addressing the acute pain.
Correct Answer is C
Explanation
Choice C rationale
Administering another nitroglycerin tablet is appropriate if the client's chest pain has not been fully relieved after the initial dose. Nitroglycerin helps to dilate blood vessels, improving blood flow to the heart and relieving angina. A second dose can be given if the pain persists, following the protocol for managing chest pain.
Choice A rationale
Obtaining an ECG is important for diagnosing and monitoring cardiac conditions; however, in this immediate context, further pain relief takes precedence. After ensuring pain relief, an ECG can be performed to assess the client's cardiac status.
Choice B rationale
Calling the Rapid Response Team is unnecessary if the client’s chest pain severity has already decreased. The priority should be to continue managing the chest pain with additional nitroglycerin if needed and monitoring the client's response.
Choice D rationale
Initiating a peripheral IV might be required for administering medications or fluids, but it is not the immediate action needed in this scenario. The priority is to provide additional pain relief with nitroglycerin.
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