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 D
Explanation
Choice D rationale
Ensuring a clear airway is the priority intervention in cases of diabetic ketoacidosis with hypoxia. Hypoxia refers to a deficiency in the amount of oxygen reaching tissues. Without a clear airway, oxygen cannot be effectively delivered to the lungs, and subsequently to the bloodstream and tissues. Addressing the client's airway ensures that oxygenation can be improved promptly, which is critical in preventing further complications and maintaining vital functions.
Choice A rationale
While it is important to monitor blood glucose levels in diabetic ketoacidosis, it is not the immediate priority when the client is also experiencing hypoxia. Blood glucose testing does not directly address the oxygen deficiency, which needs urgent attention to prevent severe outcomes.
Choice B rationale
Administering a bronchodilator can help improve breathing in some cases; however, it is not the first step in managing hypoxia and diabetic ketoacidosis. The primary focus should be on ensuring a patent airway to facilitate adequate oxygen delivery.
Choice C rationale
Monitoring vital signs is essential in managing any acute condition; however, in this scenario, ensuring a clear airway to address hypoxia is the most critical intervention. Monitoring alone does not resolve the immediate issue of oxygen deprivation.
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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