The nurse is teaching self-care to a client with a newly applied cast to the forearm. Which of the following does the nurse instruct the client to notify the practitioner immediately?
Cap refill is less than 2 seconds in the affected extremity
There is a small amount of bloody drainage on the cast.
Stiffness of the fingers.
Increasing pain at the injury site unrelieved with analgesics
The Correct Answer is D
Rationale:
A. Capillary refill less than 2 seconds indicates normal peripheral perfusion and is not a cause for concern.
B. A small amount of bloody drainage may be expected initially after injury or surgery, but it should be monitored, not necessarily reported immediately.
C. Some stiffness in the fingers is common after immobilization but does not usually require urgent attention unless it progresses or is accompanied by other symptoms.
D. Increasing pain that is unrelieved by analgesics may be a sign of compartment syndrome, a serious complication of casting that can lead to permanent damage. This is a medical emergency and must be reported immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. The Recommendation section is where the nurse suggests what action or intervention is needed (e.g., "I recommend you evaluate the patient for possible hemorrhage").
B. The Situation outlines the immediate issue (e.g., “The patient is 6 hours post-op hysterectomy and showing signs of possible deterioration”).
C. The Assessment section includes current vital signs and clinical findings such as oxygen saturation and heart rate. These data support the nurse’s clinical judgment and provide context for the concern.
D. The Background provides relevant medical history or events leading up to the current situation (e.g., "The patient underwent a total hysterectomy 6 hours ago").
Correct Answer is D
Explanation
Rationale:
A. Complex regional pain syndrome presents as chronic, severe pain and sensitivity in a limb, but it is not associated with respiratory symptoms or fever.
B. Avascular necrosis is a gradual condition resulting from loss of blood supply to bone tissue, not an acute emergency with respiratory and systemic signs.
C. Compartment syndrome presents with severe limb pain, pallor, and pulselessness, but does not cause respiratory distress or fever.
D. Fat embolism syndrome (FES) is a serious complication often seen after long bone fractures like femur fractures. Symptoms include chest pain, tachycardia, tachypnea, fever, hypoxia, and thick white sputum. It is a medical emergency requiring immediate intervention.
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