The nurse is caring for a preschool child with a cast applied recently for a fractured tibia. Which assessment finding indicates possible compartment syndrome?

Pain responding well to prescribed dose of Morphine.

ltching unrelieved by Diphenhydramine (Benadryl administration.

Lower extremities temperature cool bilaterally.

Tingling in the toes of fractured extremity and decreased sensation.

Answer and Explanation

The Correct Answer is D

Compartment syndrome is a condition characterized by increased pressure within a muscle compartment, leading to impaired blood flow and potential tissue damage. It can occur when swelling or bleeding within a confined space, such as a cast, causes increased pressure on the surrounding tissues.

Tingling in the toes and decreased sensation can be indicative of nerve compression or damage due to increased pressure in the compartment. It is important to recognize these neurological changes as potential signs of compartment syndrome.

Signs and symptoms of compartment syndrome may include:

Severe pain that is out of proportion to the injury or not relieved by pain medication.
Swelling and tightness in the affected area.
Numbness or tingling.
Pale or cool skin over the affected area.
Weakness or decreased sensation in the affected limb.
In severe cases, paralysis or loss of pulse in the affected area.

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Correct Answer is ["B","C","D","E"]

Explanation

The initial bundle of care in sepsis includes the following:

Obtain blood cultures: Blood cultures help identify the specific microorganism causing the infection, which is important for guiding appropriate antibiotic therapy.
Administer broad-spectrum antibiotics: Early administration of antibiotics is crucial in sepsis to target the suspected or likely infectious organisms. Broad-spectrum antibiotics cover a wide range of potential pathogens until more specific information from culture results is available.
Obtain lactate levels: Measuring lactate levels helps assess tissue perfusion and can be used as an indicator of the severity of sepsis. Elevated lactate levels are associated with tissue hypoperfusion and increased mortality.
Administer IV fluid bolus: Early aggressive fluid resuscitation is an essential component of sepsis management. Administering intravenous fluids helps restore intravascular volume and improve tissue perfusion.
Administration of vasopressors: Especially in the setting of hypotension and to maintain MAP above 65mmHg.

A. Administer the antibiotic earlier than scheduled. B. Administer pain medication. C. Have the client use the incentive spirometer. D. Change the dressing over the wound.

Correct Answer is C

Explanation

The assessment findings indicate that the client has diminished lung sounds in the lower lobes, suggesting potential postoperative atelectasis or decreased air movement in the lungs. Using an incentive spirometer can help improve lung expansion and prevent respiratory complications such as pneumonia. It is important to address this issue promptly to prevent further deterioration of lung function.

Administering pain medication may be necessary depending on the client's level of pain, but addressing the respiratory issue takes priority in this situation.

Administering the antibiotic earlier than scheduled or changing the dressing over the wound may not be indicated based on the provided assessment findings.

Therefore, having the client use the incentive spirometer is the most appropriate action at this time to promote optimal lung function and prevent respiratory complications.

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The nurse is caring for a preschool child with a cast applied recently for a fractured tibia. Which assessment finding indicates possible compartment syndrome?

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Naxlex Comprehensive Predictor Exams

The initial bundle of care in sepsis includes which of the following? (Select all that apply.)

Correct Answer is ["B","C","D","E"]

Explanation

Correct Answer is C

Explanation

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