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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.
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A nurse assesses a client with a rotator cuff injury. Which finding should the nurse expect to assess?
- A. Stability to maintain abduction of the affected arm for more than 90 seconds.
- B. Shoulder pain that is relieved with overhead stretches and at night.
- C. Inability to initiate or maintain abduction of the affected arm at the shoulder.
- D. Referred pain to the shoulder and arm opposite the affected shoulder.
Correct Answer: C
Rationale: Clients with a rotator cuff tear are unable to initiate or maintain abduction of the affected arm at the shoulder. This is known as the drop arm test. The client should not have difficulty with adduction of the arm, nor experience pain relief with overhead stretches. Pain is usually more intense at night and with related activities, and referred pain to the opposite shoulder is not typical.
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.
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 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.