The nurse is continuing to care for the adolescent.
Provider Prescriptions
1415:
X-ray of right leg shows open fracture of the right proximal tibia
Surgery consult
Morphine 4 mg IV every 2 hr as needed for pain.
The nurse is preparing the adolescent for the fasciotomy. Which of the following findings should the nurse report to the provider prior to surgery?
The adolescent's parents have concerns regarding the surgery.
The adolescent's blood pressure is 131/89 mm Hg.
The adolescent reports severe pain.
The adolescent has not voided in 4 hr.
The Correct Answer is A
A. Addressing parental concerns is crucial, especially for informed consent. If the parents are not comfortable or have unresolved questions, it could delay or prevent the surgery from proceeding.
B. While this blood pressure is slightly elevated, it is not an immediate concern that would typically prevent surgery.
C. Although severe pain is important to manage, it may not require immediate reporting unless it is unmanageable or indicates a serious problem.
D. While the lack of voiding in an immobile patient is a concern and could indicate urinary retention, it is not necessarily a finding that would prevent surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Pain with movement of the left great toe is incorrect finding: Pain may be expected in a client with a fractured left tibia, especially if the great toe is moved. Pain is more related to the fracture and may not specifically indicate altered tissue perfusion.
Choice B reason:
Faint pedal pulse of the left leg is correct because it indicates that the blood flow to the foot is diminished. The pedal pulse is the pulse felt on the top of the foot, and its faintness could suggest reduced arterial blood flow to the foot.
Choice C reason:
Warm skin temperature distal to the pin site is incorrect: Warm skin distal to the pin site may indicate adequate blood flow and could be a normal finding. Warmth is generally associated with increased blood flow to the area.
Choice D reason:
Purulent drainage at the pin site is incorrect. Purulent drainage at the pin site could indicate an infection, but it is not directly related to altered tissue perfusion. Infection can lead to complications, but it does not necessarily indicate reduced blood flow to the extremity
Correct Answer is B
Explanation
Choice A reason:
Mild pain in the hip region can be caused by various musculoskeletal issues, such as muscle strains, bursitis, or even referred pain from other areas. It is not a characteristic symptom of scoliosis.
Choice B reason
Scoliosis is characterized by an abnormal sideways curvature of the spine, which can cause uneven shoulders and pelvic heights. As the spine curves abnormally, it can lead to asymmetry in the shoulders and hips, which are noticeable during physical examination. This asymmetry is a key clinical sign that suggests the presence of scoliosis.
Choice C reason:
Limited range of motion (ROM) of the hips is more likely related to hip joint issues or musculoskeletal conditions affecting the hips, not specifically scoliosis.
Choice D reason:
Exaggerated curvature of the sacrum may indicate other spinal abnormalities or conditions affecting the lower back, but it is not typically associated with scoliosis, which primarily affects the curvature of the spine higher up in the thoracic or lumbar regions.
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