An emergency nurse assesses a client who is admitted with a...

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.

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A nurse plans care for a client who is recovering from open reduction and internal fixation (ORIF) surgery. Which actions should the nurse include in this client's plan of care? (Select all that apply.)

A. Elevate heels off the bed with a pillow.
B. Ambulate the client on the first postoperative day.
C. Use an abduction pillow to prevent hip subluxation.
D. Re-position the client every 2 hours.
E. Push the client's patient-controlled analgesia button.

Correct Answer: A,B,C,D

Rationale: Postoperative care for a client who has ORIF of the hip includes elevating the client's heels off the bed and repositioning every 2 hours to prevent pressure and skin breakdown, ambulating the client on the first postoperative day, and using pillows or an abduction pillow to prevent subluxation of the hip. The nurse should never push the patient-controlled analgesia button for the client.

A nurse cares for a client with a fractured fibula. Which assessment should alert the nurse to take immediate action?

A. Pain of 4 on a scale of 0 to 10.
B. Numbness in the extremity.
C. Swollen extremity at the injury site.
D. Feeling cold while lying in bed.

Correct Answer: B

Rationale: The client with numbness and/or tingling of the extremity may be displaying the first signs of acute compartment syndrome. This is an acute problem that requires immediate intervention because of possible decreased circulation. Moderate pain and swelling are expected after a fracture and can be treated with comfort measures. Feeling cold can be addressed with additional blankets or increasing the room temperature.

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 teaches a client with a fractured tibia about external fixation. Which advantages of external fixation should the nurse share with the client? (Select all that apply.)

A. It leads to minimal blood loss.
B. It allows for early ambulation.
C. It promotes healing.
D. It increases blood supply to tissues.
E. It stabilizes the fracture site.

Correct Answer: A,B,C,E

Rationale: External fixation is a system in which pins or wires are inserted through the skin and bone, connected to an external frame. It leads to minimal blood loss, allows early ambulation and exercise, maintains alignment, stabilizes the fracture site, and promotes healing. It does not increase blood supply to the tissues.

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.