The nurse is caring for a client who sustained a crushed injury to the lower extremity and has developed compartment syndrome. What intervention should the nurse plan for next?

Insertion of central venous access

Phlebotomy

Fasciotomy

Insertion of arterial line

Answer and Explanation

The Correct Answer is C

A. Insertion of central venous access: This is not relevant to compartment syndrome management. Central venous access is used for fluid administration or monitoring central venous pressure.

B. Phlebotomy: This is unrelated to the management of compartment syndrome, as it involves drawing blood and does not address the increased pressure.

C. Fasciotomy: Compartment syndrome is a medical emergency where increased pressure within a closed compartment compromises circulation and tissue function. A fasciotomy involves surgically opening the compartment to relieve the pressure, prevent tissue necrosis, and save the limb. This is the definitive treatment.

D. Insertion of arterial line: While this may be useful for monitoring blood pressure in critical situations, it does not relieve compartment syndrome.

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Correct Answer is C

Explanation

A. The new graduate nurse elevates the client's head of the bed to 30 degrees. Elevating the head of the bed to 30 degrees helps reduce ICP by promoting venous drainage from the brain.

B. The new graduate nurse administers an analgesic before turning the client. Analgesics are often necessary before turning a client with a head injury to minimize discomfort and prevent additional stress.

C. The new graduate nurse is frequently suctioning the client without breaks: Frequent suctioning without breaks can increase intracranial pressure (ICP) and compromise the patient's condition. Suctioning should be done with caution and only as needed, allowing for breaks in between to prevent ICP elevation.

D. The new graduate nurse assesses the client's neurologic status every hour. Regular neuro assessments are necessary for patients with head injuries to monitor changes in condition.

A. Administer oxygen via nasal cannula B. Administer prescribed pain medications C. Administer NS IV fluid D. Ask the provider for a dopamine prescription

Correct Answer is A

Explanation

A. Administer oxygen via nasal cannula: The client's symptoms of dyspnea, chest pain, syncope, and hypotension suggest a possible acute cardiovascular event, such as a myocardial infarction (MI) or pulmonary embolism (PE). Administering oxygen should be the priority to improve oxygenation and prevent hypoxia, which could exacerbate the client's symptoms and further compromise cardiac function.

B. Administer prescribed pain medications. Pain relief may be necessary, but stabilizing oxygen levels is the priority.

C. Administer NS IV fluid. Fluid administration may be helpful, but oxygenation is more critical in this situation to address the potential underlying respiratory or cardiac issue.

D. Ask the provider for a dopamine prescription. While dopamine may be used in cases of shock, the immediate action should be to ensure the client is adequately oxygenated.

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The nurse is caring for a client who sustained a crushed injury to the lower extremity and has developed compartment syndrome. What intervention should the nurse plan for next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is A

Explanation

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