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
Prednisone is a corticosteroid medication that can cause a range of side effects, including fluid retention, electrolyte imbalance, and increased blood pressure. A blood pressure reading of 148/94 mm Hg indicates hypertension, which may be related to the use of prednisone. It is essential to report this finding to the health care provider as it may require further evaluation and management, such as adjusting the medication dosage or initiating additional treatments to control blood pressure. The other information provided, such as stopping the medication, ankle edema, and not taking prescribed vitamin D, is relevant but does not pose an immediate threat to the patient's health compared to uncontrolled hypertension.
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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