Nokea
A nurse is caring for a client admitted to the emergency department with suspected rhabdomyolysis. Which of the following findings would the nurse anticipate in a client with this condition?
- A. Elevated creatinine kinase (CK) levels
- B. Decreased serum potassium levels
- C. Hypertension and bradycardia
- D. Clear urine output
Correct Answer: A
Rationale: Rhabdomyolysis causes muscle breakdown, releasing creatinine kinase (CK) into the blood, elevating levels. Potassium levels typically rise, blood pressure and heart rate vary, and urine is dark from myoglobin.
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The nurse in the emergency department is presented with two severed fingers from a client who experienced a traumatic amputation. What should the nurse do to properly preserve the severed fingers for possible reattachment?
- A. Apply direct pressure to the severed fingers and wrap them in gauze.
- B. Irrigate the amputated fingers with sterile saline.
- C. Place the amputated fingers directly on ice.
- D. Wrap the fingers in gauze, put it in a plastic bag, and then place the bag in ice water.
Correct Answer: D
Rationale: To preserve severed fingers for potential reattachment, wrap them in sterile gauze, place them in a sealed plastic bag, and then place the bag in ice water. Direct pressure is for bleeding control, not preservation. Irrigation is appropriate but incomplete. Direct ice contact can cause tissue damage from freezing.
The nurse is caring for a client with a newly applied plaster cast. The nurse should
- A. Use a small object like a pencil or ruler to itch the leg if it becomes uncomfortable.
- B. Expedite drying by using a hot blow dryer on the cast.
- C. Let the cast hang below the heart to promote blood flow.
- D. Handle the cast with the palms of the hands.
Correct Answer: D
Rationale: Handling a wet plaster cast with the palms prevents denting, which could cause pressure points. Scratching inside risks skin damage, hot dryers can burn, and a dependent position increases swelling.
The nurse educates a client about the application of a plaster cast to a fractured radius. Which of the following statements by the client would require follow-up?
- A. If my arm feels itchy, I can use a hair dryer on the cool setting for relief.'
- B. I can reduce my arm's swelling by elevating it with a pillow.'
- C. I should be okay to shower with my cast.'
- D. It will be normal for me to feel heat after the cast is applied.'
Correct Answer: C
Rationale: Showering with a plaster cast risks wetting it, leading to breakdown or infection, requiring follow-up. Cool air for itching, elevation for swelling, and initial heat from cast setting are appropriate.
The nurse is caring for a client with a femur fracture. The client reports chest pain, restlessness, and dyspnea. The nurse suspects that the client has developed fat embolism syndrome (FES). The nurse should take which action?
- A. Place the extremity in a dependent position
- B. Obtain a prescription for hypertonic intravenous fluids
- C. Loosen any dressings on the extremity
- D. Notify the physician
Correct Answer: D
Rationale: Chest pain, restlessness, and dyspnea suggest fat embolism syndrome, a medical emergency. Notifying the physician is critical for rapid intervention. Dependent positioning worsens swelling, hypertonic fluids are unrelated, and loosening dressings helps but is secondary.
The nurse performs a focused assessment on a casted patient experiencing increased pain in the affected limb. The nurse notes pallor and swelling distal to the cast area. The patient reports increased pain upon passively moving the extremity. Which of the following fracture-related complications should the nurse be concerned about?
- A. Fat embolism
- B. Infection
- C. Pulmonary embolism
- D. Compartment syndrome
Correct Answer: D
Rationale: Pallor, swelling, and increased pain with passive movement are classic signs of compartment syndrome, a serious complication from pressure buildup in a casted limb. Fat and pulmonary embolisms involve systemic symptoms, and infection typically includes fever.