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 B
Explanation
Dumping syndrome is a common complication after Gastric Bypass surgery, where food moves too quickly from the stomach to the small intestine. It occurs when the undigested contents of the stomach are "dumped" rapidly into the small intestine, leading to symptoms such as nausea, vomiting, abdominal cramps, diarrhea, lightheadedness, and sweating.
To manage dumping syndrome, it is important for the client to avoid foods and beverages that are high in sugar and carbohydrates. Consuming these types of foods can trigger rapid gastric emptying and exacerbate the symptoms. Instead, the client should focus on a well-balanced diet that includes lean proteins, healthy fats, and complex carbohydrates.
Correct Answer is D
Explanation
Cholelithiasis refers to the presence of gallstones in the gallbladder or bile ducts. The most common symptom is right upper quadrant abdominal pain, which may be colicky or steady. Nausea and vomiting are also commonly associated with cholelithiasis.
Coffee ground emesis and constipation are not typical findings associated with cholelithiasis. Absent bowel sounds may be a sign of bowel obstruction but are not specific to cholelithiasis.
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