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A nurse assesses a client with a cast for potential compartment syndrome. Which clinical manifestations are correctly paired with the physiologic changes of compartment syndrome? (Select all that apply.)
- A. Edema "? Increased capillary permeability
- B. Pallor "? Increased blood flow to the area
- C. Unequal pulses "? Increased production of lactic acid
- D. Cyanosis "? Anaerobic metabolism
- E. Tingling "? A release of histamine
Correct Answer: A,C,D
Rationale: Clinical manifestations of compartment syndrome are caused by several physiologic changes. Edema is caused by increased capillary permeability, unequal pulses are caused by increased production of lactic acid, and cyanosis is caused by anaerobic metabolism. Pallor is caused by decreased oxygen to tissues, not increased blood flow, and tingling is caused by increased tissue pressure, not histamine release.
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A nurse teaches a client who is at risk for carpal tunnel syndrome. Which health promotion activities should the nurse include in this client's teaching? (Select all that apply.)
- A. Frequently assess the ergonomics of the equipment being used.
- B. Take breaks to stretch fingers and wrists during working hours.
- C. Perform wrist exercises to strengthen muscles.
- D. Adjust activities to increase pain and swelling in wrists.
- E. Use wrist splints during repetitive tasks.
Correct Answer: A,B,C,E
Rationale: To prevent carpal tunnel syndrome, the nurse should teach the client to assess the ergonomics of their workspace, take breaks to stretch fingers and wrists, perform wrist exercises to strengthen muscles, and use wrist splints during repetitive tasks. Adjusting activities to increase pain and swelling would worsen the condition and should not be recommended.
A nurse cares for a client who had a long-leg cast applied last week. The client states, 'I cannot seem to catch my breath and I feel a bit light-headed.' Which action should the nurse take next?
- A. Auscultate the client's lung fields anteriorly and posteriorly.
- B. Administer oxygen via nasal cannula.
- C. Check the client's oxygen saturation.
- D. Notify the healthcare provider immediately.
Correct Answer: D
Rationale: Shortness of breath and light-headedness in a client with a long-leg cast may indicate a pulmonary embolism, a serious complication possibly related to fat embolism syndrome from the fracture. Notifying the healthcare provider immediately is the priority to ensure rapid evaluation and treatment. Auscultation, oxygen administration, and checking oxygen saturation are secondary actions that may follow after the provider is notified.
An emergency nurse assesses a client who is admitted with a pelvic fracture. Which assessments should the nurse monitor? (Select all that apply.)
- A. Temperature
- B. Urinary output
- C. Blood pressure
- D. Pulse rate
- E. Level of consciousness
Correct Answer: A,B,C,D,E
Rationale: A client with a pelvic fracture is at risk for complications such as internal bleeding, infection, and shock. Monitoring temperature can indicate infection, urinary output can reflect kidney function or hypovolemia, blood pressure and pulse rate can indicate hemodynamic stability, and level of consciousness can signal neurological changes or shock. These assessments are critical for client safety.
A nurse cares for a client placed in skeletal traction. The client asks, What is the primary purpose of this type of traction? How should the nurse respond?
- A. This traction will prevent fat aligning your fractured bone.
- B. This traction will prevent future complications and back pain.
- C. Traction decreases muscle spasms that occur with a fracture.
- D. This type of traction minimizes damage as a result of fracture treatment.
Correct Answer: A
Rationale: Skeletal traction pins or screws are surgically inserted into the bone to aid in bone alignment. As a secondary benefit, traction can be used to relieve pain, decrease muscle spasm, and prevent or correct deformity and tissue damage, but these are not the primary purposes of skeletal traction.
A nurse cares for an older adult client with multiple fractures. Which action should the nurse take to manage this client's pain?
- A. Administer meperidine every 4 hours around the clock.
- B. Patient-controlled analgesia (PCA) pump with morphine.
- C. Ibuprofen (Motrin) 600 mg orally every 4 hours PRN for pain.
- D. Morphine 2 mg intravenous push every 4 hours PRN for pain.
Correct Answer: B
Rationale: The older adult client should not be treated with meperidine because toxic metabolites can cause seizures. A PCA pump with morphine is the best option for controlling pain in this client. Ibuprofen may not provide sufficient pain relief for multiple fractures, and PRN morphine may not maintain consistent pain control.