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A nurse cares for a client with a fracture injury. Twenty minutes after an opioid pain medication is administered, the client reports pain in the site of the fracture. Which actions should the nurse take? (Select all that apply.)
- A. Administer additional opioids as prescribed.
- B. Elevate the extremity on pillows.
- C. Apply ice to the fracture site.
- D. Apply heat to the fracture site.
- E. Keep the extremity in a dependent position.
Correct Answer: A,B,C
Rationale: The client with a new fracture likely has edema; elevating the extremity and applying ice will help in decreasing pain and swelling. Administration of additional opioids within dosage guidelines may be ordered. Heat and dependent positioning will increase edema and potentially worsen pain.
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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.
An emergency department nurse stages a client with diabetes mellitus who has fractured her arm. Which action should the nurse take first?
- A. Remove the medical alert bracelet from the fractured arm.
- B. Immobilize the arm by splinting the fractured site.
- C. Apply a sling to support the fractured arm.
- D. Cover any open areas with a sterile dressing.
Correct Answer: A
Rationale: A client's medical alert bracelet should be removed from the fractured arm before the affected extremity swells. Immobilization, positioning, and dressing should occur after the bracelet is removed to ensure client safety.
A nurse cares for a client in skeletal traction. The nurse notes that the skin around the client's pin sites is swollen, red, and crusty with dried drainage. Which action should the nurse take next?
- A. Request a prescription to decrease the traction weight.
- B. Apply a warm compress to reduce swelling.
- C. Cleanse the area twice, scrubbing off the crusty areas.
- D. Obtain a prescription to culture the drainage.
Correct Answer: D
Rationale: These clinical manifestations indicate inflammation and possible infection. Obtaining a prescription to culture the drainage is the appropriate action to identify and treat a potential infection. Decreasing traction weight or scrubbing the area could exacerbate the issue, and a warm compress may not address the underlying infection.
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.
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.