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 A
Explanation
Recombinant human erythropoietin is a medication commonly used in the treatment of anemia associated with chronic renal failure. It stimulates the production of red blood cells in the bone marrow, helping to improve anemia.
The other statements mentioned do not accurately reflect the expected outcomes or effects of recombinant human erythropoietin:
Chronic renal failure leads to impaired kidney function, and while recombinant human erythropoietin can help address anemia, it does not directly improve creatinine (Cr) and blood urea nitrogen (BUN) levels, which are markers of kidney function.
Furosemide is a diuretic commonly used in the management of fluid retention in renal failure. Recombinant human erythropoietin does not replace or eliminate the need for diuretic therapy.
Chronic renal failure typically involves decreased kidney function and impaired urine production. Recombinant human erythropoietin does not directly affect urine output.
Correct Answer is D
Explanation
Aspiration refers to the inhalation of gastric contents or other substances into the respiratory tract. During surgery, when the patient is under general anesthesia, the protective airway reflexes may be suppressed, increasing the risk of aspiration. If stomach contents enter the lungs, it can lead to aspiration pneumonia, respiratory distress, and other complications.
While myocardial infarction (MI), hernia, and cerebral vascular accident (CVA) are possible complications that can occur during surgery, they are not specifically related to airway issues.
MI is a cardiac event involving the blood supply to the heart muscle, hernia refers to the protrusion of an organ or tissue through an abnormal opening, and CVA refers to a disruption of blood flow to the brain. These complications can have various causes but are not directly related to the airway during surgery.
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