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
Cushing's syndrome is a disorder characterized by excessive production or prolonged exposure to high levels of glucocorticoids, particularly cortisol. This can occur due to various reasons, such as the use of corticosteroid medications or overproduction of cortisol by the adrenal glands. Elevated glucocorticoid levels result in a variety of clinical manifestations associated with Cushing's syndrome, including weight gain, central obesity, muscle wasting, thinning of the skin, easy bruising, and impaired glucose metabolism.
It's important to note that Cushing's syndrome can have different underlying causes, such as adrenal tumors, pituitary tumors, or ectopic ACTH production. Regardless of the cause, the common feature in Cushing's syndrome is the excessive glucocorticoid levels, which contribute to the signs and symptoms of the condition.
Correct Answer is D
Explanation
Compartment syndrome is a condition characterized by increased pressure within a muscle compartment, leading to impaired blood flow and potential tissue damage. It can occur when swelling or bleeding within a confined space, such as a cast, causes increased pressure on the surrounding tissues.
Tingling in the toes and decreased sensation can be indicative of nerve compression or damage due to increased pressure in the compartment. It is important to recognize these neurological changes as potential signs of compartment syndrome.
Signs and symptoms of compartment syndrome may include:
- Severe pain that is out of proportion to the injury or not relieved by pain medication.
- Swelling and tightness in the affected area.
- Numbness or tingling.
- Pale or cool skin over the affected area.
- Weakness or decreased sensation in the affected limb.
- In severe cases, paralysis or loss of pulse in the affected area.
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