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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Administering a prescribed bronchodilator medication is the priority action for a patient experiencing an acute asthma attack. This helps to open the airways and improve breathing.
Choice B rationale
While checking the patient's vital signs is important, it is not the first action in the acute management of an asthma attack. The immediate priority is to relieve bronchospasm.
Choice C rationale
Collecting a sputum sample for analysis is not the first priority in an acute asthma attack. Stabilizing the patient's breathing is more urgent.
Choice D rationale
Obtaining a detailed health history is essential for comprehensive care but is not the first action during an acute asthma attack. Rapid intervention to improve breathing is the priority.
Correct Answer is C
Explanation
Choice A rationale
Clamping the chest tube can cause increased pressure in the pleural space and is not appropriate without specific indications.
Choice B rationale
Increasing the wall suction may not relieve the burning sensation and could potentially cause harm.
Choice C rationale
Repositioning the client can help alleviate the burning sensation by adjusting the position of the chest tube and the lung.
Choice D rationale
Stripping the chest tube is not recommended as it can increase intrathoracic pressure and cause damage.
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