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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.
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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.
After teaching a client with a fractured humerus, the nurse assesses the client's understanding. Which dietary choice demonstrates that the client correctly understands the nutrition needed to assist in healing the fracture?
- A. Baked fish with orange juice and a vitamin D supplement.
- B. Bacon, lettuce, and tomato sandwich with a vitamin B supplement.
- C. Bacon, lettuce, and tomato sandwich with a vitamin C supplement.
- D. Roast beef with low-fat milk and a vitamin C supplement.
Correct Answer: D
Rationale: The client with a healing fracture needs supplements of vitamins B and C and a high-protein, high-calorie diet. Milk provides calcium supplementation, and vitamin C aids in healing. Roast beef provides high protein, making this the best choice. Fish and sandwiches provide less protein.
A phone triage nurse speaks with a client who has an arm cast. The client states, 'My arm feels really tight and puffy.' How should the nurse respond?
- A. Elevate your arm on two pillows and get ice to apply to the cast.
- B. Continue to take ibuprofen (Motrin) until the swelling subsides.
- C. This is normal. A new cast will often feel a little tight for the first few days.
- D. Please come to the clinic today to have your arm checked by the provider.
Correct Answer: D
Rationale: Puffy fingers and a feeling of tightness from the cast may indicate the development of compartment syndrome. The client should come to the clinic that day to be evaluated by the provider because delay of treatment can cause permanent damage to the extremity. Ice and ibuprofen are acceptable actions, but checking the cast is the priority to ensure client safety. The nurse should not reassure the client that this is normal.
Which intervention should the nurse include in this client's plan of care for a client recovering from a below-the-knee amputation?
- A. Place pillows between the client's knees.
- B. Encourage range-of-motion exercises.
- C. Administer prophylactic antibiotics.
- D. Implement strict bedrest in a supine position.
Correct Answer: B
Rationale: Clients with a below-the-knee amputation should complete range-of-motion exercises to prevent flexion contractures and prepare for a prosthesis. A pillow may be used under the limb as support. Clients recovering from this type of amputation are at low risk for infection and should not be prescribed prophylactic antibiotics. The client should be encouraged to reposition, move, and exercise frequently, and therefore should not implement strict bedrest.
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.