Nokea
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.
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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.
The following scenario applies to the next 1 items
The nurse in the emergency department (ED) is caring for a 17-year-old male client.
Item 1 of 1
History and Physical
1722: The client has had an external fixation on the left wrist for the past two weeks. Today, he noticed swelling, increased pain, fever, and reports purulent drainage from the pin sites. The client reports poor adherence to performing pin care at home. On exam, the client is febrile and has an oral temperature of 103.4° F (39.7° C). The left wrist is erythemic, swollen, and tender to the touch.
The nurse has reviewed the history and physical. For each potential intervention, click to specify whether the intervention is indicated or not indicated for the client.
- A. Obtain a prescription for an antibiotic
- B. Culture the pin sites
- C. Apply a pressure dressing over the pins
- D. Obtain a prescription for analgesia
- E. Position the client's wrist so it is extended
Correct Answer: A: Indicated, B: Indicated, C: Not Indicated, D: Indicated, E: Not Indicated
Rationale: A: Antibiotics treat infection suggested by fever and drainage. B: Cultures identify the organism. C: Pressure dressings may damage pins or tissue. D: Analgesia addresses pain. E: Extension may worsen swelling and pain.
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 in the medical-surgical unit is caring for a newly admitted client.
Item 3 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.
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.
The nurse reviews the consultation report from the infectious disease physician. Select the complications that the client is at risk for developing? Select all that apply.
- A. Rheumatoid arthritis
- B. Osteosarcoma
- C. Avascular necrosis
- D. Sepsis
- E. Paget's disease
- F. Hyperosmolar hyperglycemic nonketotic syndrome
Correct Answer: C, D
Rationale: With suspected osteomyelitis and uncontrolled diabetes, the client risks avascular necrosis due to poor blood supply and sepsis from untreated infection spreading. Rheumatoid arthritis and osteosarcoma are unrelated, and Paget's is a chronic bone disorder.
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.