Nokea
The nurse is assessing a client in skeletal traction, and the findings show a pale and cold foot with an unpalpable pulse. What is the priority nursing intervention?
- A. Reassess the foot in twenty minutes
- B. Readjust the traction
- C. Administer the ordered PRN medication
- D. Notify the primary healthcare provider (PHCP)
Correct Answer: D
Rationale: A pale, cold foot with no pulse suggests acute neurovascular compromise, a medical emergency. Notifying the PHCP is the priority for immediate intervention. Reassessment delays care, traction adjustment risks harm, and medication doesn't address the cause.
You may also like to solve these questions
The nurse is caring for a client who has a fiberglass cast that has just been applied to their left arm due to a humerus fracture. Three hours later, the client complains of numbness in his fingers, and says his fingers 'have become pale.' What is the nurse's most appropriate action?
- A. Reassure the client that this is just a normal occurrence after having a cast.
- B. Ask the client to clench his fist frequently.
- C. Remove the cast immediately.
- D. Notify the primary healthcare provider (PHCP).
Correct Answer: D
Rationale: Numbness and pallor in the fingers are signs of potential compartment syndrome or impaired circulation, which are serious complications. The most appropriate action is to notify the primary healthcare provider immediately for further evaluation and intervention. Reassuring the client or asking them to clench their fist does not address the urgency, and removing the cast is not within the nurse's scope without a provider's order.
The nurse in the medical-surgical unit is caring for a newly admitted client.
Item 5 of 6
History and Physical
1930: Client is a 45-year-old male who has a one-and-a-half-week history of pain, redness, and swelling in his right foot. He reported that the symptoms began after he accidentally cut his foot while walking barefoot in his backyard. Over the next few days, he developed pain and swelling around the cut, accompanied by redness and warmth. He went to urgent care two days later and was diagnosed with cellulitis in his right foot. He was prescribed antibiotics but could not afford the treatment. Three days ago, the pain escalated and was described as throbbing and constant, with a severity rating of 7/10 on the Numerical Pain Rating Scale. He states, "the pain is now in the bone of my foot; I don't know how else to describe it." He also noted occasional fever 101°F (38.3°C), chills, and general malaise. On physical examination, his right foot was erythematous, swollen, and warm to the touch. A 3 cm ulcer was noted on the plantar aspect of the right foot, with moderate purulent discharge present. The ulcer appeared deep, and palpation of the surrounding tissue elicited tenderness. There was limited range of motion in the right ankle due to pain. The distal pulses were palpable 2+, and there were signs of neuropathy in the feet (decreased sensation to light touch and pinprick). He has a medical history of uncontrolled diabetes mellitus (type two), obesity, peripheral neuropathy in all extremities, hypertension, hyperlipidemia, and epilepsy.
Orders
2100:
Magnetic resonance imaging of the right foot without contrast
Insert peripheral vascular access device
Laboratory tests: blood culture and sensitivity (C & S), complete blood count (CBC), complete metabolic panel (CMP), lactic acid
vancomycin 1 g, IV, every 12 hours
Wound culture
fentanyl 50 mcg IV, every 5 hours PRN pain
Consultation
Infectious Disease Consultation
2050: Client was evaluated and I strongly suspect osteomyelitis in his right foot. Labs are pending. Agree with admission and will follow closely.
Nurses' Notes
2110: Orders received and reviewed. Vital signs: T 103° F (39.4° C), P 92, RR 18, BP 141/87, pulse oximetry reading 98% on room air. Client reports pain '8' on the Numerical Pain Scale.
The nurse reviews the physician's orders, client's laboratory data, and makes an entry into the nurses' notes. Which of the following actions should the nurse take?
- A. Withhold administering the prescribed antibiotic and notify the physician.
- B. Place a dressing over the client's wound before transporting the client to MRI.
- C. Notify the physician to hold the ordered MRI because of the client's kidney function.
- D. Instruct the client to remove all metal objects before the MRI.
- E. Administer prescribed pain medication before the MRI.
- F. Irrigate the wound with 0.9% sodium chloride (normal saline) before obtaining wound culture.
- G. Request a prescription for a nonsteroidal anti-inflammatory drug.
Correct Answer: B, D, E, F
Rationale: B: A dressing protects the wound during transport. D: Removing metal prevents MRI interference. E: Pain medication improves comfort for MRI. F: Irrigation ensures a clean sample for culture. A and C require more data, and G is not urgent.
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.
A client with a history of statin use presents to the clinic with complaints of muscle weakness and pain. The nurse suspects myopathy. Which of the following laboratory tests should the nurse prioritize to evaluate for muscle damage?
- A. Electrocardiogram (ECG)
- B. Liver function tests (LFTs)
- C. Creatine kinase (CK)
- D. Complete blood count (CBC)
Correct Answer: C
Rationale: Creatine kinase (CK) levels rise with muscle damage, common in statin-induced myopathy. ECG is for cardiac issues, LFTs monitor liver, and CBC is not specific to muscle damage.
The nurse performs a home safety assessment for an older adult with rheumatoid arthritis. The nurse should make which recommendation to promote safety in the bathroom?
- A. Recommend using a handheld (adjustable) shower head
- B. Advise the client to lower the toilet seat to its lowest level
- C. Instruct the client to reduce bathroom lighting
- D. Recommend the use of towel racks for grab bars
Correct Answer: A
Rationale: A handheld shower head allows the client with rheumatoid arthritis to bathe more easily, accommodating limited mobility and joint stiffness. Lowering the toilet seat may make standing difficult, reduced lighting increases fall risk, and towel racks are not sturdy enough for support.