A client sustained a left femur fracture 3 hours ago. Initial vital signs and assessment were within normal limits with the exception of left leg pain.
The nurse re-assesses the client and documents the following:
- Temp: 37.2 C Pain: 7/10-chest 5/10 left leg.
- Pulse: 110 bpm
- Respirations: 40 breaths per min, labored 02 saturation: 88%
- Neuro: A&O x 3. Anxious Skin: Petechiae to neck and anterior chest.
Based on this assessment, which action is appropriate at this time?
Notify the healthcare provider that the client's pain is not well-managed
Reassure the client that the pain and stress of the fracture will soon get better.
Order a chest CT Computerized Tomography) to rule out a pulmonary embolus (PE).
Notify the healthcare provider that the client may have a fat embolism
The Correct Answer is D
Fat embolism syndrome can occur when fat globules enter the bloodstream after a long bone fracture, such as a femur fracture. The fat globules can travel to the lungs and cause respiratory distress and decreased oxygen saturation. The symptoms observed in the client, including tachypnea (labored breathing), decreased oxygen saturation (88%), and the presence of petechiae (small red or purple spots) on the neck and anterior chest, are consistent with fat embolism syndrome.
Fat embolism syndrome is a serious condition that requires immediate medical attention. Notifying the healthcare provider allows for prompt evaluation, confirmation of the diagnosis, and initiation of appropriate treatment. This may involve further diagnostic tests such as a chest CT scan, as mentioned in one of the options, to rule out other potential causes or complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["Lithotripsy"," Encourage increased fluid intake"]
Explanation
Lithotripsy and Encourage increased fluid intake are the most important interventions.
Correct Answer is B
Explanation
The given observations suggest the occurrence of malignant hyperthermia (MH), a potentially life-threatening reaction to certain medications used during anesthesia. MH is characterized by an increase in heart rate (tachycardia), elevated body temperature (hyperthermia), and muscle rigidity. The primary treatment for MH is the administration of dantrolene, which is a skeletal muscle relaxant that helps to counteract the effects of the reaction.
Naloxone (Narcan) is an opioid receptor antagonist used to reverse the effects of opioid overdose or excessive opioid sedation.
Furosemide (Lasix) is a diuretic used to treat conditions such as edema and high blood pressure.
Flumazenil (Romazicon) is a benzodiazepine receptor antagonist used to reverse the effects of benzodiazepine overdose or excessive sedation.
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