The nurse is caring for a patient who just returned from surgical decompression of the carpal tunnel. Which finding requires the nurse's immediate action?
The patient's fingers are pink and cool bilaterally.
The capillary refill time is 8 seconds.
The patient complains of generalized pain 5/10.
The patient's fingers swollen and warm.
The Correct Answer is B
A. Fingers being pink and cool bilaterally may be expected postoperatively due to anesthesia or positioning and does not indicate an immediate complication.
B. A capillary refill time of 8 seconds is significantly prolonged (normal is ≤2 seconds) and may indicate compromised circulation, possibly due to compartment syndrome or vascular compromise. This requires immediate action to preserve limb function.
C. A pain level of 5/10 is moderate and may be expected after surgery. It does not indicate an urgent issue unless unrelieved by medication or out of proportion to the procedure.
D. Swollen and warm fingers may be part of the normal inflammatory process after surgery but are not immediately life- or limb-threatening.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Diazepam is a benzodiazepine that acts quickly to stop active seizures and is the first-line medication for status epilepticus.
B. Lisinopril is an antihypertensive and not used for seizure management.
C. Atenolol is a beta-blocker used for cardiac conditions and not related to seizure treatment.
D. Phenytoin is used for seizure prevention and maintenance therapy but is not the initial emergency treatment for status epilepticus.
Correct Answer is B
Explanation
A. Circulatory congestion of the skin does not directly cause the intense, deep pain associated with osteomyelitis.
B. Osteomyelitis is an infection of the bone, often involving the bone marrow. The buildup of purulent material increases pressure within the rigid bone structure, causing severe pain.
C. While casts can cause discomfort if improperly applied, the primary source of pain in osteomyelitis is the infection itself.
D. Inelastic bone structure may contribute to pressure buildup, but this is secondary to the infection in the bone marrow, which is the direct cause of pain.
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