Review Hesi med surg proctored exam 2 herzing university

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Hesi med surg proctored exam 2 herzing university

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Question 1:

The nurse is preparing an older adult client with renal failure for hemodialysis. The client also has dementia, so is easily distracted. To prevent infection, which intervention is most important for the nurse to implement?

A. Put a mask on the client. B. Have staff wear protective clothing. C. Orient the client during procedure. D. Access AV port using sterile gloves.

Answer and Explanation

Choice A:

Put a mask on the client: Placing a mask on the client may reduce the spread of respiratory microorganisms, particularly if the client has respiratory symptoms such as coughing or sneezing. Although masks may be recommended in some dialysis units during catheter access procedures, wearing a mask alone does not provide the highest level of protection against vascular access infections. Prevention of bloodstream infection depends primarily on maintaining strict aseptic technique when accessing the dialysis site.

Choice B:

Have staff wear protective clothing: Healthcare personnel should wear appropriate personal protective equipment (PPE), including gloves and, when indicated, gowns, masks, or eye protection, to reduce exposure to blood and body fluids and prevent cross-contamination. However, protective clothing alone does not ensure that microorganisms are excluded from the vascular access site. Sterile technique during cannulation of the AV access remains the most important intervention for preventing infection.

Choice C:

Orient the client during procedure: Reorienting a client with dementia can reduce anxiety, improve cooperation, and decrease agitation during the hemodialysis procedure. Although this intervention promotes safety and may help prevent accidental movement during cannulation, it does not directly prevent infection. Infection prevention requires meticulous aseptic handling of the vascular access site rather than cognitive support measures.

Choice D:

Access AV port using sterile gloves: Using sterile gloves and strict aseptic technique when accessing the arteriovenous fistula or graft is the most important nursing intervention to prevent infection. The AV access provides direct entry into the circulatory system, and contamination during cannulation can result in local infection, bacteremia, or life-threatening sepsis. Proper hand hygiene, skin antisepsis with an appropriate disinfectant, sterile gloves, and adherence to evidence-based infection prevention practices significantly reduce the risk of vascular access-related infections, making this the highest-priority intervention.

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Question 2:

A client is admitted with flash burns to the anterior surface of both arms, anterior trunk, and anterior surface of both legs. Using the rule of nines, which total percentage of the client's skin surface is burned? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

Answer and Explanation

Correct Answer: "45" %

Explanation

The Rule of Nines is a rapid assessment tool used to estimate the percentage of total body surface area (TBSA) affected by burns in adults. Accurate calculation of TBSA is essential because it guides fluid resuscitation (e.g., using the Parkland formula), determines burn severity, assists with prognosis, and helps identify the need for transfer to a specialized burn center. In adults, specific body regions are assigned standardized percentages that collectively total 100% of the body surface area.

Calculation:

Anterior surface of both arms = 9%
- Anterior surface of one arm = 4.5%
- Both anterior arms = 9%
Anterior trunk = 18%
Anterior surface of both legs = 18%
- Anterior surface of one leg = 9%
- Both anterior legs = 18%

Total TBSA burned = 9% + 18% + 18%

= 45%

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Question 3:

A client with acute kidney injury (AKI) is admitted to the medical telemetry unit with a serum potassium level of 7.8 mEq/L (7.8 mmol/L). Which action should the nurse implement first?

Reference Range:

Potassium (K+) [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

A. Administer prescription for sodium polystyrene sulfonate 30 grams PO. B. Insert an indwelling urinary catheter and measure hourly urinary output. C. Schedule hemodialysis treatment as soon as possible. D. Evaluate telemetry strip for aberrant T-wave formation.

Answer and Explanation

Choice A:

Administer prescription for sodium polystyrene sulfonate 30 grams PO: Sodium polystyrene sulfonate (Kayexalate) lowers serum potassium by exchanging sodium for potassium within the gastrointestinal tract, allowing potassium to be eliminated through the feces. Although this medication helps reduce potassium levels, its onset of action is relatively slow, often requiring several hours to produce a significant effect. Because severe hyperkalemia can cause fatal cardiac dysrhythmias before the medication becomes effective, assessment of cardiac status takes priority over administering this treatment.

Choice B:

Insert an indwelling urinary catheter and measure hourly urinary output: Monitoring urinary output is important in clients with acute kidney injury because it provides valuable information regarding renal perfusion, progression of kidney injury, and response to therapy. However, insertion of a urinary catheter does not address the immediate life-threatening complication of severe hyperkalemia. Cardiac monitoring and rapid identification of ECG changes must occur first because dysrhythmias can develop suddenly and require immediate intervention.

Choice C:

Schedule hemodialysis treatment as soon as possible: Hemodialysis is one of the most effective methods for rapidly removing potassium from the bloodstream and is often indicated in clients with severe hyperkalemia that is refractory to medical management or associated with significant renal failure. However, arranging dialysis requires coordination and cannot be initiated instantaneously. Before dialysis is performed, the nurse must assess for evidence of cardiac instability, continuously monitor the client's rhythm, and implement emergency measures if dysrhythmias occur.

Choice D:

Evaluate telemetry strip for aberrant T-wave formation: Severe hyperkalemia can rapidly produce characteristic electrocardiographic changes, including tall peaked T waves, shortened QT interval, prolonged PR interval, widening of the QRS complex, loss of P waves, sine-wave morphology, ventricular fibrillation, and asystole. Because these abnormalities may precede sudden cardiac arrest, immediate evaluation of the telemetry strip is the highest-priority nursing action. Early identification of ECG changes allows prompt initiation of emergency therapies such as intravenous calcium gluconate, insulin with dextrose, beta₂-adrenergic agonists, sodium bicarbonate when indicated, and preparation for urgent dialysis if necessary.

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Question 4:

The nurse is reviewing the laboratory results for a client with chronic kidney disease (CKD). Which laboratory value should the nurse identify as lower than normal due to insufficient renal function?

Reference Range:

Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]

Glycosylated hemoglobin A1C (HbA1C) [Good control: less than 7%]

Creatinine [0.6 to 1.2 mg/dL (53 to 106 μmol/L)]

A. Hemoglobin [14 to 18 g/dL (140 to 180 g/L)] B. Serum potassium 6.5 mEq/L (6.5 mmol/L). C. Glycosylated hemoglobin A1C (HbA1C) 10%. D. Hemoglobin of 8 g/dL (80 g/L). E. Serum creatinine 3.6 mg/dL (318 μmol/L).

Answer and Explanation

Choice A:

Hemoglobin 14 to 18 g/dL (140 to 180 g/L): A hemoglobin level within the reference range indicates normal oxygen-carrying capacity and adequate erythropoiesis. In clients with chronic kidney disease, diminished erythropoietin production typically results in decreased red blood cell production and anemia rather than normal hemoglobin values. Therefore, this laboratory value does not reflect the expected hematologic consequence of insufficient renal function.

Choice B:

Serum potassium 6.5 mEq/L (6.5 mmol/L): Hyperkalemia is a common complication of chronic kidney disease because the kidneys are unable to adequately excrete potassium. A serum potassium level of 6.5 mEq/L is significantly elevated and places the client at risk for life-threatening cardiac dysrhythmias, including ventricular tachycardia and cardiac arrest. Although this abnormality is consistent with impaired renal function, the question specifically asks which laboratory value would be lower than normal,.

Choice C:

Glycosylated hemoglobin A1C (HbA1C) 10%: An HbA1C of 10% indicates poorly controlled diabetes mellitus over the previous two to three months and is a major risk factor for the development and progression of diabetic nephropathy. However, this value reflects chronic hyperglycemia rather than a laboratory abnormality caused directly by decreased renal function. It is elevated, not decreased.

Choice D:

Hemoglobin of 8 g/dL (80 g/L): A hemoglobin level of 8 g/dL represents significant anemia and is the expected laboratory finding resulting from chronic kidney disease. Diseased kidneys produce insufficient erythropoietin, leading to reduced stimulation of the bone marrow and decreased red blood cell production. This normocytic, normochromic anemia contributes to fatigue, weakness, pallor, reduced exercise tolerance, dyspnea, and decreased oxygen delivery to tissues. Management often includes erythropoiesis-stimulating agents and iron supplementation when appropriate, making this the correct answer.

Choice E:

Serum creatinine 3.6 mg/dL (318 μmol/L): Serum creatinine is a marker of renal function that rises as glomerular filtration rate (GFR) declines. A creatinine level of 3.6 mg/dL indicates significant impairment of kidney function and reduced clearance of metabolic waste products. Although this finding is characteristic of chronic kidney disease, it represents an elevated laboratory value rather than one that is lower than normal.

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Question 5:

A skin substitute was placed on a client who experienced a full-thickness burn to the upper and lower right arm 4 hours ago. The client has a dressing from fingers to shoulder on the affected arm. Which intervention(s) should the nurse implement? Select all that apply.

A. Determine pain level using a pain scale. B. Encourage active range-of-motion exercises every 4 hours. C. Routine dressing changes every 8 hours. D. Evaluate temperature every 4 hours. E. Monitor pulse and capillary refill every 2 hours. F. Keep the arm extended and elevate on a pillow.

Answer and Explanation

Choice A:

Determine pain level using a pain scale: Pain assessment is an essential nursing intervention even after a full-thickness burn because surrounding tissues, donor sites, and partially injured nerve endings can produce significant pain. In addition, placement of a skin substitute and associated surgical manipulation contribute to postoperative discomfort. Regular assessment using a standardized pain scale allows the nurse to evaluate the effectiveness of analgesic therapy, identify increasing pain that may indicate complications.

Choice B:

Encourage active range-of-motion exercises every 4 hours: Active range-of-motion exercises are important during burn rehabilitation to prevent joint contractures and preserve mobility. However, immediately following placement of a skin substitute, excessive movement of the affected extremity may disrupt graft adherence, impair revascularization, and increase the risk of graft failure. The grafted extremity is generally immobilized during the initial postoperative period, and range-of-motion exercises are initiated only when prescribed by the burn team after sufficient graft stabilization has occurred.

Choice C:

Routine dressing changes every 8 hours: Routine dressing changes are generally avoided during the immediate postoperative period following placement of a skin substitute because unnecessary manipulation can disrupt graft adherence, introduce microorganisms, and impair healing. Burn dressings are typically changed only according to the surgeon's or burn specialist's protocol or when there is evidence of excessive drainage, bleeding, or suspected infection. Frequent scheduled dressing changes without a clinical indication are therefore inappropriate.

Choice D:

Evaluate temperature every 4 hours: Burn clients are at increased risk for infection because destruction of the skin barrier facilitates microbial invasion. Fever may be an early indicator of wound infection or systemic sepsis, particularly following extensive burns or surgical procedures involving skin substitutes. Regular monitoring of body temperature enables early detection of infection and timely initiation of diagnostic evaluation and antimicrobial therapy when indicated, making this an important nursing intervention.

Choice E:

Monitor pulse and capillary refill every 2 hours: Frequent neurovascular assessment is a priority because edema beneath circumferential dressings can compromise arterial blood flow to the distal extremity. Assessing peripheral pulses, capillary refill, skin temperature, color, and sensation allows early identification of impaired perfusion or compartment syndrome, which requires immediate intervention to prevent ischemia, tissue necrosis, and permanent loss of function. Neurovascular checks should be performed regularly during the early postoperative period.

Choice F:

Keep the arm extended and elevate on a pillow: Elevating the affected extremity above the level of the heart helps reduce edema by promoting venous and lymphatic drainage while decreasing tissue pressure around the graft. Maintaining the arm in an extended functional position also helps prevent flexion contractures and preserves joint mobility during healing. Proper positioning supports graft viability, improves circulation, reduces pain, and contributes to optimal long-term functional recovery.

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Question 6:

While performing a neurovascular assessment distal to a client's fracture site, the nurse determines that the client's pulse is present, regular, and full force. Which nursing action should be taken next?

A. Discontinue elevating the client's affected extremity. B. Observe the color of the extremity. C. Notify the healthcare provider (HCP) of assessment finding. D. Document the neurovascular assessment as normal.

Answer and Explanation

Choice A:

Discontinue elevating the client's affected extremity: Elevation of an injured extremity is commonly recommended during the acute phase after a fracture to reduce edema and minimize pain, provided arterial circulation remains adequate. A normal distal pulse is not an indication to discontinue elevation because swelling may still compromise tissue perfusion. Unless there is evidence of impaired arterial blood flow or compartment syndrome requiring a change in management, the nurse should continue the assessment before altering the plan.

Choice B:

Observe the color of the extremity: A comprehensive neurovascular assessment requires evaluation of additional indicators of tissue perfusion after confirming the presence of a distal pulse. Assessing skin color helps identify pallor, cyanosis, or mottling, which may indicate compromised arterial circulation despite a palpable pulse. The nurse should also assess capillary refill, temperature, sensation, movement, and pain to determine whether adequate tissue perfusion and neurological function are maintained. Completing the assessment systematically ensures early detection of vascular compromise or compartment syndrome.

Choice C:

Notify the healthcare provider (HCP) of assessment finding: A distal pulse that is present, regular, and full is an expected finding and does not require immediate notification of the healthcare provider. Notification is warranted only if abnormal findings such as absent or diminished pulses, increasing pain unrelieved by analgesics, pallor, paresthesia, paralysis, delayed capillary refill, or coolness of the extremity suggest acute neurovascular compromise. Additional assessment data should be obtained before deciding to escalate care.

Choice D:

Document the neurovascular assessment as normal: Documentation should occur only after the entire neurovascular examination has been completed. Although the pulse is normal, this single finding is insufficient to conclude that overall neurovascular status is intact because abnormalities in sensation, motor function, skin color, temperature, or capillary refill may still be present. Accurate documentation requires a complete assessment of all neurovascular parameters rather than relying on one normal component.

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Question 7:

A 36-year-old male client is brought to the emergency department (ED) following a fall from a ladder approximately 12 ft (3.6 m) high. Reports falling onto his right side and is experiencing pain in his right arm, hip, and leg. Bruising is evident in the client's right thigh. Client denies losing consciousness or hitting his head. He is obese and is a current smoker, smoking one pack per day. Reports an intermittent productive cough for the past five years. Has an incomplete fracture to the right femur. Surgical consultation has been completed, and the client is being admitted to the orthopedic floor for surgery the following morning.

1400

Client is admitted to the orthopedic unit. Initial prescriptions are placed by the healthcare provider (HCP) and an initial assessment and vital signs completed.

Assessment

Neurological: Alert and oriented to person, place, time, and situation Full sensation bilateral lower extremities. Denies numbness and tingling.

Cardiovascular: Heart sounds normal. Regular rhythm. Left leg 2+ dorsalis pedal pulses and 2+ posterior tibial pulses. Right leg 1+ dorsalis pedal pulses and 1+ posterior tibial pulses. Capillary refill 3 seconds bilateral lower extremities.

Respiratory: Lung sounds are clear in all fields. No signs of respiratory distress, productive cough.

Gastrointestinal: Denies nausea, vomiting, and diarrhea. Reported last bowel movement this morning.

Genitourinary: Indwelling urinary catheter in place. Clear straw colored urine is visible in the catheter bag.

Musculoskeletal: Full range of motion (ROM) in bilateral ankles. Throbbing pain 6 on a 0 to 10 scale reported in right upper leg. 3+ edema in right lower extremity.

20 gauge peripheral IV (PIV) catheter placed in the client's right forearm basilic vein. Secured and maintained per unit protocol. Client tolerated procedure well.

1400

Temperature 98.1° F (36.7° C)

Heart rate 85 beats/minute

Respirations 14 breaths/minute

Blood pressure 119/62 mm Hg

Oxygen saturation 98% on room air

Pain rating of 6 on a 0 to 10 scale, right leg

Body mass index of 32.1 kg/m2 (normal 18 to 24.9 kg/m2)

1400

Bedrest

Regular diet

NPO at midnight

Insert peripheral IV (PIV) catheter and maintain per unit protocol

Acetaminophen 650 mg PO every 6 hours PRN for mild pain

Tramadol 50 mg PO every 6 hour, PRN for intermediate pain

Hydromorphone 0.5 mg IV push every 2 hours PRN for severe pain

Place indwelling urinary catheter for immobility

Report urinary output less than 30 mL/hr

Titrate oxygen via nasal cannula1 to 5 L/minute to keep oxygen saturation greater than 92%

Select the 3 findings that the nurse should prioritize.

A. Reported pain 6 on a 0 to 10 scale, right leg B. Clear straw colored urine 200 mL output C. Productive cough D. 3+ edema in right lower extremity E. Bruising to right leg F. Reported last bowel movement this morning G. Right leg 1+ dorsalis pedal pulses and 1+ posterior tibial pulses H. Capillary refill 3 seconds bilateral lower extremities

Answer and Explanation

Choice A:

Reported pain 6 on a 0 to 10 scale, right leg: Pain following a femoral fracture should be carefully evaluated, particularly if it appears disproportionate to the injury or worsens despite analgesic therapy. Increasing or persistent pain may represent the earliest manifestation of acute compartment syndrome, in which elevated pressure within the fascial compartment compromises tissue perfusion. The nurse should assess the quality, severity, and progression of the pain while performing a complete neurovascular assessment to identify signs of ischemia requiring immediate intervention.

Choice B:

Clear straw-colored urine, 200 mL output: Clear, straw-colored urine with an output of 200 mL indicates adequate renal perfusion and hydration. The healthcare provider's prescription specifies reporting urine output less than 30 mL/hour, and this client's urinary output is well above that threshold. The absence of hematuria also decreases concern for associated genitourinary trauma. Therefore, this finding does not require immediate nursing intervention.

Choice C:

Productive cough: A chronic productive cough in a client who reports smoking one pack of cigarettes daily for five years is consistent with chronic airway irritation and possible chronic bronchitis. Although respiratory assessment remains important, the client has clear lung sounds, normal respiratory rate, oxygen saturation of 98% on room air, and no evidence of respiratory distress. Consequently, the cough does not represent the highest-priority problem at this time compared with findings suggesting impaired circulation to the injured extremity.

Choice D:

3+ edema in right lower extremity: Significant edema following a femoral fracture suggests extensive soft tissue injury and increased interstitial pressure. Progressive swelling can compromise arterial blood flow and compress peripheral nerves, increasing the risk of acute compartment syndrome. The nurse should closely monitor the affected limb for increasing pain, paresthesia, pallor, paralysis, poikilothermia, and diminished pulses while promptly reporting worsening edema or signs of neurovascular deterioration.

Choice E:

Bruising to right leg: Bruising is an expected finding after blunt trauma and indicates soft tissue injury with localized bleeding beneath the skin. Although extensive bruising should be monitored because femoral fractures can result in significant blood loss into surrounding tissues, bruising alone does not indicate immediate neurovascular compromise. The nurse should continue to observe the area for expansion, increasing swelling, or signs of hemorrhage, but it is not the highest-priority assessment finding.

Choice F:

Reported last bowel movement this morning: A bowel movement earlier the same day represents normal gastrointestinal function. The client denies nausea, vomiting, abdominal pain, or constipation, and there is no indication of bowel obstruction or impaired gastrointestinal motility. Therefore, this finding is expected and does not require urgent nursing intervention.

Choice G:

Right leg 1+ dorsalis pedal pulses and 1+ posterior tibial pulses: Diminished distal pulses compared with the unaffected extremity suggest reduced arterial perfusion to the injured limb. Weak pedal pulses following a femoral fracture may indicate vascular compression from edema, hematoma formation, or compartment syndrome. The nurse should immediately perform a comprehensive neurovascular assessment, compare findings with the unaffected leg, monitor for progression of ischemia, and promptly notify the healthcare provider if circulation continues to deteriorate.

Choice H:

Capillary refill 3 seconds bilateral lower extremities: A capillary refill time of approximately 3 seconds is only slightly prolonged and, because it is bilateral, may reflect normal variation, environmental temperature, or the client's baseline circulation rather than localized vascular compromise. In contrast, the unilateral reduction in pedal pulses and significant edema are much more specific indicators of impaired perfusion to the injured extremity. Although capillary refill should continue to be monitored, it is not among the highest-priority findings.

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Question 8:

1400

Client is admitted to the orthopedic unit. Initial prescriptions are placed by the healthcare provider (HCP) and an initial assessment and vital signs completed.

Assessment

Neurological: Alert and oriented to person, place, time, and situation Full sensation bilateral lower extremities. Denies numbness and tingling.

Respiratory: Lung sounds are clear in all fields. No signs of respiratory distress, productive cough.

Gastrointestinal: Denies nausea, vomiting, and diarrhea. Reported last bowel movement this morning.

Genitourinary: Indwelling urinary catheter in place. Clear straw colored urine is visible in the catheter bag.

Musculoskeletal: Full range of motion (ROM) in bilateral ankles. Throbbing pain 6 on a 0 to 10 scale reported in right upper leg. 3+ edema in right lower extremity.

20 gauge peripheral IV (PIV) catheter placed in the client's right forearm basilic vein. Secured and maintained per unit protocol. Client tolerated procedure well.

1400

Temperature 98.1° F (36.7° C)

Heart rate 85 beats/minute

Respirations 14 breaths/minute

Blood pressure 119/62 mm Hg

Oxygen saturation 98% on room air

Pain rating of 6 on a 0 to 10 scale, right leg

Body mass index of 32.1 kg/m2 (normal 18 to 24.9 kg/m2)

1400

Bedrest

Regular diet

NPO at midnight

Insert peripheral IV (PIV) catheter and maintain per unit protocol

Acetaminophen 650 mg PO every 6 hours PRN for mild pain

Tramadol 50 mg PO every 6 hour, PRN for intermediate pain

Hydromorphone 0.5 mg IV push every 2 hours PRN for severe pain

Place indwelling urinary catheter for immobility

Report urinary output less than 30 mL/hr

Titrate oxygen via nasal cannula1 to 5 L/minute to keep oxygen saturation greater than 92%

Click to indicate if the listed characteristic is consistent with a fat embolism or blood clot embolism. Each column must have at least one response option selected.

A. Tachycardia B. Origin typically long bone fracture C. Petechiae D. Origin typically deep vein thrombosis E. Altered mental status F. Chest pain G. Dyspnea

Answer and Explanation

Explanation

Characteristic	Blood clot embolism	Fat embolism
Tachycardia	✔	✔
Origin typically long bone fracture		✔
Petechiae		✔
Origin typically deep vein thrombosis	✔
Altered mental status		✔
Chest pain	✔	✔
Dyspnea	✔	✔

Differentiating a fat embolism syndrome (FES) from a blood clot (pulmonary thromboembolism, PE) in a client with a long bone fracture is critical. Fat embolism commonly develops 24–72 hours after fractures of long bones, when fat droplets from bone marrow enter the circulation and obstruct pulmonary and systemic vessels. In contrast, a pulmonary embolism results from a thrombus, most commonly originating from a deep vein thrombosis (DVT), that travels to the pulmonary vasculature. Although both conditions may present with respiratory distress and tachycardia, several hallmark findings help distinguish between them.

Rationale

• Tachycardia: Tachycardia is consistent with both blood clot embolism and fat embolism because both conditions impair pulmonary circulation and reduce oxygen delivery to tissues. The resulting hypoxemia stimulates sympathetic nervous system activation, causing an increased heart rate to maintain cardiac output. Tachycardia is therefore a common but nonspecific finding that cannot independently distinguish between the two conditions.

• Origin typically long bone fracture: A fat embolism typically originates after fractures of long bones such as the femur, tibia, or pelvis. Bone marrow fat enters the venous circulation through disrupted blood vessels and travels to the pulmonary capillaries, where it obstructs blood flow and triggers an inflammatory response. In contrast, a blood clot embolism usually originates from a thrombus in the deep veins of the lower extremities rather than from bone marrow fat. Therefore, a long bone fracture strongly supports fat embolism rather than thromboembolism.

• Petechiae: Petechiae are a classic finding of fat embolism syndrome and result from embolization of fat droplets into dermal capillaries and associated platelet aggregation. They commonly appear on the chest, neck, axillae, shoulders, and conjunctiva within 24 to 72 hours after injury. Blood clot embolism does not typically produce petechial hemorrhages because thromboemboli obstruct larger pulmonary vessels rather than causing widespread capillary damage. Therefore, petechiae are considered highly characteristic of fat embolism.

• Origin typically deep vein thrombosis: A blood clot embolism most commonly results from a thrombus that forms in the deep veins of the legs or pelvis due to venous stasis, endothelial injury, or hypercoagulability (Virchow's triad). Portions of the clot may detach and travel through the venous circulation to the pulmonary arteries, producing a pulmonary embolism. Fat embolism does not arise from venous thrombosis but instead originates from marrow fat released after orthopedic trauma.

• Altered mental status: Altered mental status is strongly associated with fat embolism syndrome because fat globules may enter the systemic circulation and lodge within cerebral capillaries, causing cerebral hypoxia and neurological dysfunction. Clients may develop confusion, agitation, restlessness, decreased level of consciousness, or seizures. Blood clot embolism primarily affects pulmonary circulation and usually does not produce neurological symptoms unless severe hypoxemia occurs.

• Chest pain: Chest pain may occur with both blood clot embolism and fat embolism because both conditions reduce pulmonary perfusion and cause inflammation or ischemia within the lungs. In pulmonary embolism, chest pain is often sudden, sharp, and pleuritic due to irritation of the pleura. In fat embolism, chest discomfort results from pulmonary capillary obstruction and the accompanying inflammatory response. Therefore, chest pain alone does not distinguish between the two disorders.

• Dyspnea: Dyspnea is a hallmark manifestation of both blood clot embolism and fat embolism because each condition interferes with pulmonary gas exchange. Obstruction of pulmonary vessels decreases oxygenation, resulting in shortness of breath, tachypnea, and hypoxemia. In pulmonary embolism, dyspnea often has a sudden onset, whereas in fat embolism it typically develops within 24–72 hours after the fracture. Despite differences in onset, dyspnea is expected in both conditions.

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Question 9:

2030

The client reports throbbing pain 8 on a 0 to 10 scale. Administered hydromorphone 0.5 mg IV push (IVP). 2200

Acetaminophen 650 mg PO is given for throbbing pain reported 3 on a 0 to 10 scale.

2230

The client reports throbbing pain 8 on a 0 to 10 scale. Administered hydromorphone 0.5 mg IVP. Assessment

Neurological: Anxious. Full sensation bilateral lower extremities. Denies numbness and tingling.

Cardiovascular: Heart rhythm normal though tachycardic. Diaphoretic. Left leg 3+ dorsalis pedal pulses and 3+ posterior tibial pulses. Right leg 1+ dorsalis pedal pulses and 1+ posterior tibial pulses. Capillary refill 3 seconds bilateral lower extremities. Petechiae on neck and upper chest.

Respiratory: Fine crackles left lower lobe. Right lung sounds clear. Tachypneic. Dyspnea with use of accessory muscles.

Gastrointestinal: Active bowel sounds.

Genitourinary: Indwelling urinary catheter draining straw colored urine 130 mL output in 4 hours.

1800

Temperature: 99° F (37.2° C) orally

Heart rate: 81 beats/minute

Respirations: 13 breaths/minute

Blood pressure: 118/64 mm Hg

Oxygen saturation: 99% on room air

Pain: 4 on a 0 to 10 scale, right leg

2200:

Temperature 98.7" F (37.1" C) orally

Heart rate: 86 beats/minute

Respirations: 15 breaths/minute

Blood pressure: 126/72 mm Hg

Oxygen saturation: 97% on room air

Pain: 3 on a 0 to 10 scale, right leg

1400

Bedrest

Regular diet

NPO at midnight

Insert peripheral IV (PIV) catheter and maintain per unit protocol

Acetaminophen 650 mg PO every 6 hours PRN for mild pain

Tramadol 50 mg PO every 6 hour, PRN for intermediate pain

Hydromorphone 0.5 mg IV push (IVP) every 2 hours PRN for severe pain

Place indwelling urinary catheter for immobility

Report urinary output less than 30 mL/hr

Titrate oxygen via nasal cannula1 to 5 L/minute to keep oxygen saturation greater than 92%

Computed tomography (CT) chest: Pulmonary edema in right lung and patch distribution of opacities consistent with embolism.

Drag from Word Choices to complete the sentence.

A client with pulmonary fat embolus is at highest risk for as a result of mismatched lung perfusion and alveolar gas exchange with oxygenation.

Answer and Explanation

Explanation

This question evaluates the nurse's understanding of the primary complication associated with fat embolism syndrome (FES) following a long bone fracture. Fat embolism occurs when fat globules from bone marrow enter the bloodstream and lodge within the pulmonary capillaries, causing mechanical obstruction and an intense inflammatory response. This disrupts ventilation-perfusion (V/Q) matching and impairs alveolar gas exchange, making respiratory compromise the most immediate and life-threatening concern.

Rationale for correct choice:

• Hypoxemia: Hypoxemia is the most significant complication of pulmonary fat embolism because fat globules obstruct pulmonary capillaries and trigger inflammation that damages the alveolar-capillary membrane. This results in ventilation-perfusion mismatch, where portions of the lung are ventilated but inadequately perfused, or perfused but unable to participate effectively in oxygen exchange. Consequently, arterial oxygen levels fall despite supplemental oxygen, leading to dyspnea, tachypnea, accessory muscle use, and crackles, all of which are present in this client. If untreated, severe hypoxemia may progress to acute respiratory distress syndrome (ARDS) and respiratory failure.

Rationale for incorrect choices:

• Hypercoagulation: Hypercoagulation refers to an increased tendency for blood clot formation and is associated with conditions such as deep vein thrombosis and pulmonary thromboembolism. Although trauma and immobility increase the risk of thrombosis, the client's findings of petechiae, long bone fracture, and CT evidence are most consistent with a fat embolism, not a thrombotic embolism. The primary pathophysiology involves fat globules obstructing pulmonary vessels rather than abnormal blood coagulation.

• Hypotension: Hypotension may occur in severe fat embolism syndrome due to systemic inflammation or right ventricular dysfunction, but it is not the direct consequence of ventilation-perfusion mismatch. The client's blood pressure remains stable, and the primary physiological disturbance is impaired oxygen diffusion across the alveolar-capillary membrane. Respiratory compromise and hypoxemia develop before significant hemodynamic instability in most cases. Therefore, hypotension is not the highest-priority complication in this scenario.

• Hypercapnia: Hypercapnia is characterized by elevated arterial carbon dioxide levels resulting from inadequate ventilation. During the early stages of fat embolism syndrome, clients typically develop tachypnea, which increases carbon dioxide elimination and often maintains or lowers PaCO₂. The major impairment involves oxygen diffusion rather than carbon dioxide clearance because carbon dioxide diffuses across the alveolar membrane much more readily than oxygen. Consequently, hypoxemia develops earlier and is more clinically significant than hypercapnia.

• Hyperbicarbonatemia: Hyperbicarbonatemia indicates elevated serum bicarbonate levels and is generally associated with metabolic alkalosis or chronic compensation for respiratory acidosis. Fat embolism syndrome does not directly increase bicarbonate concentration. Instead, the primary abnormalities involve impaired oxygenation, pulmonary inflammation, and ventilation-perfusion mismatch. Therefore, elevated bicarbonate levels are not expected as a direct consequence of pulmonary fat embolism.

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Question 10:

2030

The client reports throbbing pain 8 on a 0 to 10 scale. Administered hydromorphone 0.5 mg IV push (IVP). 2200

Acetaminophen 650 mg PO is given for throbbing pain reported 3 on a 0 to 10 scale.

2230

The client reports throbbing pain 8 on a 0 to 10 scale. Administered hydromorphone 0.5 mg IVP. Assessment

Neurological: Anxious. Full sensation bilateral lower extremities. Denies numbness and tingling.

Respiratory: Fine crackles left lower lobe. Right lung sounds clear. Tachypneic. Dyspnea with use of accessory muscles.

Gastrointestinal: Active bowel sounds.

Genitourinary: Indwelling urinary catheter draining straw colored urine 130 mL output in 4 hours.

1800

Temperature: 99° F (37.2° C) orally

Heart rate: 81 beats/minute

Respirations: 13 breaths/minute

Blood pressure: 118/64 mm Hg

Oxygen saturation: 99% on room air

Pain: 4 on a 0 to 10 scale, right leg

2200:

Temperature 98.7° F (37.1° C) orally

Heart rate: 86 beats/minute

Respirations: 15 breaths/minute

Blood pressure: 126/72 mm Hg

Oxygen saturation: 97% on room air

Pain: 3 on a 0 to 10 scale, right leg

1400

Bedrest

Regular diet

NPO at midnight

Insert peripheral IV (PIV) catheter and maintain per unit protocol

Acetaminophen 650 mg PO every 6 hours PRN for mild pain

Tramadol 50 mg PO every 6 hour, PRN for intermediate pain

Hydromorphone 0.5 mg IV push (IVP) every 2 hours PRN for severe pain

Place indwelling urinary catheter for immobility

Report urinary output less than 30 mL/hr

Titrate oxygen via nasal cannula1 to 5 L/minute to keep oxygen saturation greater than 92%

Computed tomography (CT) chest: Pulmonary edema in right lung and patch distribution of opacities consistent with embolism.

Which laboratory studies are indicated to support the diagnosis of pulmonary fat embolism? Select all that apply.

A. Platelet count B. Aspartate aminotransferase (AST) C. Serum calcium D. Glomerular filtration rate (GFR) E. Triglycerides F. Arterial oxygen partial pressure (PaO2) G. Alanine transaminase (ALT) H. Erythrocyte sedimentation rate (ESR) I. Red blood cell count

Answer and Explanation

Choice A:

Platelet count: A decreased platelet count (thrombocytopenia) is commonly associated with fat embolism syndrome because platelets aggregate around circulating fat globules and are consumed during the inflammatory process. Activation of coagulation pathways and endothelial injury further contribute to platelet consumption. Thrombocytopenia is therefore one of the characteristic laboratory findings that supports the diagnosis of pulmonary fat embolism, particularly when accompanied by respiratory compromise and petechiae.

Choice B:

Aspartate aminotransferase (AST): AST is a hepatic and muscle enzyme primarily used to assess hepatocellular injury or skeletal muscle damage. Although trauma may cause mild elevations in AST, it is neither sensitive nor specific for pulmonary fat embolism. Elevated AST does not contribute significantly to confirming the diagnosis and is not routinely included among the laboratory studies used to evaluate fat embolism syndrome.

Choice C:

Serum calcium: Serum calcium may occasionally decrease because circulating free fatty acids released during fat embolism bind with calcium to form insoluble soaps. However, hypocalcemia is an inconsistent finding and lacks sufficient sensitivity or specificity to support the diagnosis of fat embolism syndrome. Therefore, serum calcium is not considered one of the primary laboratory studies used to establish this diagnosis.

Choice D:

Glomerular filtration rate (GFR): Glomerular filtration rate is an indicator of renal function and is commonly used to evaluate chronic kidney disease or acute kidney injury. Pulmonary fat embolism primarily affects the pulmonary and neurological systems rather than renal filtration. Although severe systemic illness may secondarily impair kidney function, GFR is not a diagnostic laboratory marker for fat embolism syndrome.

Choice E:

Triglycerides: Elevated serum triglyceride or free fat levels support the diagnosis because fat embolism results from the release of marrow fat into the circulation following long-bone fractures. Although measurement of circulating fat is not diagnostic on its own, increased triglyceride concentrations may provide laboratory evidence consistent with fat embolization when interpreted alongside the client's clinical presentation of respiratory distress, petechiae, and neurological findings.

Choice F:

Arterial oxygen partial pressure (PaO₂): A decreased PaO₂ is one of the most important laboratory findings in pulmonary fat embolism syndrome. Fat globules obstruct the pulmonary capillary bed and trigger widespread inflammation, producing ventilation-perfusion mismatch, impaired diffusion, and hypoxemia. Arterial blood gas analysis typically demonstrates reduced oxygen tension, making PaO₂ an essential study to support the diagnosis and assess the severity of respiratory compromise.

Choice G:

Alanine transaminase (ALT): ALT is a liver-specific enzyme that reflects hepatocellular injury rather than pulmonary or hematologic abnormalities. While trauma or shock may occasionally affect liver function, ALT does not provide meaningful diagnostic information for fat embolism syndrome. Consequently, it is not routinely obtained to support this diagnosis.

Choice H:

Erythrocyte sedimentation rate (ESR): The erythrocyte sedimentation rate (ESR) is often elevated because fat embolism syndrome produces a significant systemic inflammatory response. Although ESR is a nonspecific inflammatory marker and cannot confirm the diagnosis independently, an elevated value supports the presence of inflammation when interpreted together with the client's clinical findings, imaging studies, hypoxemia, thrombocytopenia, and elevated circulating fat levels.

Choice I:

Red blood cell count: Red blood cell count is not a specific laboratory marker for pulmonary fat embolism syndrome. Although trauma-related blood loss may decrease the erythrocyte count, anemia reflects hemorrhage rather than fat embolization. Changes in red blood cell count do not contribute to confirming the diagnosis of fat embolism syndrome and therefore are not considered diagnostic laboratory findings.

Discussion Section

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