Nokea
A client who underwent peripheral arterial bypass surgery 16 hours ago reports that there is increasing pain in the leg that worsens with movement and is accompanied by paresthesias. Based on these data, which action should the nurse take?
- A. Call the primary health care provider.
- B. Administer an opioid analgesic.
- C. Apply warm moist heat for comfort.
- D. Apply ice to minimize any developing swelling.
Correct Answer: A
Rationale: Compartment syndrome is characterized by increased pressure within a muscle compartment caused by bleeding or excessive edema. It compresses the nerves in the area and can cause vascular compromise. The classic signs of compartment syndrome are pain at rest that intensifies with movement and the development of paresthesias. Compartment syndrome is an emergency, and the primary health care provider is notified immediately because the client could require an emergency fasciotomy to relieve the pressure and restore perfusion.
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A primary health care provider prescribes acetaminophen liquid 450 mg orally every 4 hours PRN for pain. The medication label reads 160 mg/5 mL. The nurse prepares how many milliliters (mL) to administer one dose? Fill in the blank and record your answer to the nearest whole number.
Correct Answer: 14 mL
Rationale: Use the formula for calculating medication dosages. Formula: Desired × Volume / Available = mL per dose. 450 mg × 5 mL / 160 mg = 14 mL.
Which nursing assessment question should be asked to help determine the client's risk for developing malignant hyperthermia in the perioperative period?
- A. Have you ever had heat exhaustion or heat stroke?
- B. What is the normal range for your body temperature?
- C. Do you or any of your family members have frequent infections?
- D. Do you or any of your family members have problems with general anesthesia?
Correct Answer: D
Rationale: Malignant hyperthermia is a genetic disorder in which a combination of anesthetic agents (the muscle relaxant succinylcholine and inhalation agents such as halothanes) triggers uncontrolled skeletal muscle contractions that can quickly lead to a potentially fatal hyperthermia. Questioning the client about the family history of general anesthesia problems may reveal this as a risk for the client. Options 1, 2, and 3 are unrelated to this surgical complication.
The nurse is encouraging the client to cough and deep breathe after cardiac surgery. The nurse ensures that which item is available to maximize the effectiveness of this procedure?
- A. Nebulizer
- B. Ambu bag
- C. Suction equipment
- D. Incisional splinting pillow
Correct Answer: D
Rationale: The use of an incisional splint such as a 'cough pillow' can ease discomfort during coughing and deep breathing. The client who is comfortable will do more effective deep breathing and coughing exercises. Use of an incentive spirometer is also indicated. Options 1, 2, and 3 will not encourage the client to cough and deep breathe.
The nurse is caring for a client who has experienced a thoracic spinal cord injury. In the event that spinal shock occurs, which intravenous (IV) fluid should the nurse anticipate being prescribed?
- A. Dextran
- B. 0.9% normal saline
- C. 5% dextrose in water
- D. 5% dextrose in 0.9% normal saline
Correct Answer: B
Rationale: Normal saline 0.9% is an isotonic solution that primarily remains in the intravascular space, increasing intravascular volume. This IV fluid would increase the client's blood pressure. Dextran is rarely used in spinal shock because isotonic fluid administration is usually sufficient. Additionally, Dextran has potential adverse effects. Dextrose 5% in water is a hypotonic solution that pulls fluid out of the intravascular space and is not indicated for shock. Dextrose 5% in normal saline 0.9% is hypertonic and may be indicated for shock resulting from hemorrhage or burns.
The nurse, while caring for a hospitalized infant being monitored for increased intracranial pressure (ICP), notes that the anterior fontanel bulges when the infant cries. Based on this assessment finding, which conclusion should the nurse draw?
- A. That no action is required.
- B. The head of the bed needs to be lowered.
- C. The infant needs to be placed on NPO status.
- D. The primary health care provider should be notified immediately.
Correct Answer: A
Rationale: A bulging anterior fontanel in an infant when crying is a normal finding, as crying increases intracranial pressure temporarily. This does not indicate a pathological condition requiring immediate intervention. Lowering the head of the bed or placing the infant on NPO status is not warranted, and notifying the primary health care provider is unnecessary unless other signs of increased ICP, such as persistent bulging at rest, irritability, or lethargy, are present.