A client is reporting pain in her casted leg. The nurse has administered analgesics and elevated the limb. Thirty minutes after administering the analgesics. the client states the pain is unrelieved. The nurse is unable to palpate the client's dorsalis pedis or posterior tibial pulse and the client's foot is pale. The nurse suspects compartment syndrome. What is the nurse's most appropriate action?
Promptly inform the primary provider.
Reassess the client's neurovascular status in 15 minutes.
Warm the client's foot and determine whether circulation improves.
Reposition the client with the affected foot dependent.
The Correct Answer is A
Explanation:
A. Promptly inform the primary provider:
Explanation: Compartment syndrome is a medical emergency that requires immediate intervention. If a nurse suspects compartment syndrome due to symptoms like severe unrelieved pain, absent pulses, and pale extremities, the most appropriate action is to promptly inform the primary healthcare provider. The provider can assess the situation, order necessary diagnostic tests, and potentially arrange for emergent interventions like fasciotomy to relieve compartment pressure.
B. Reassess the client's neurovascular status in 15 minutes:
Explanation: Waiting for 15 minutes to reassess the client's neurovascular status is not appropriate in this situation. Compartment syndrome can progress rapidly, leading to irreversible tissue damage within a short time frame. Delaying assessment and intervention can result in significant complications.
C. Warm the client's foot and determine whether circulation improves:
Explanation: Warming the foot is not appropriate in this context. Compartment syndrome is caused by increased pressure within the muscle compartment, leading to compromised circulation. Warming the foot will not address the underlying issue of elevated compartment pressure and can potentially worsen the condition by dilating blood vessels and increasing pressure further.
D. Reposition the client with the affected foot dependent:
Explanation: Repositioning the client with the affected foot dependent is contraindicated in compartment syndrome. Elevating the limb can worsen the condition by further restricting blood flow. The limb should be kept at or slightly below the level of the heart to maintain adequate perfusion until medical intervention can be initiated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Sedentary lifestyle - Lack of weight-bearing exercise and physical activity is a significant risk factor for the development of osteoporosis. Weight-bearing exercises help maintain bone density and strength. Sedentary individuals are more prone to osteoporosis.
B. Long-term use of diuretics - Long-term use of certain medications, such as corticosteroids, can increase the risk of osteoporosis. Diuretics are not typically associated with osteoporosis risk, although some medications can affect bone health.
C. Prolonged stress - Chronic stress can have negative effects on overall health, but it is not a direct risk factor for osteoporosis.
D. Obesity - Obesity is generally considered a protective factor against osteoporosis. Individuals with higher body weight tend to have stronger bones due to the mechanical load placed on the bones, reducing the risk of osteoporosis.
Correct Answer is ["200"]
Explanation
To calculate the rate at which the nurse should program the pump in milliliters per hour, you can use the following formula:
Rate (mL/hour) = Volume (mL) / Time (hours)
In this case, the volume is 1,000 mL (1 liter), and the time is 5 hours. Plugging these values into the formula:
Rate (mL/hour) = 1,000 mL / 5 hours = 200 mL/hour
So, the nurse should program the pump to administer the normal saline at a rate of 200 milliliters per hour.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.