A client with a fracture of the left arm that has been set in a cast complains of severe, diffuse pain that is unrelieved by pain medication. The nurse notes that the pulse distal to the site of injury has weakened and that the tissue is pale. Which of the following nursing actions should the nurse perform first?
Contact the health care provider.
Administer PRN pain medication.
Document the findings.
Elevate the extremity.
The Correct Answer is A
Choice A Reason: Contacting the health care provider is the first nursing action that the nurse should perform, as it indicates that the client may have compartment syndrome, which is a medical emergency that requires immediate intervention to prevent tissue necrosis and nerve damage.
Choice B Reason: Administering PRN pain medication is not the first nursing action that the nurse should perform, as it may not relieve the pain and may mask the symptoms of compartment syndrome.
Choice C Reason: Documenting the findings is not the first nursing action that the nurse should perform, as it may delay the treatment and worsen the outcome of compartment syndrome.
Choice D Reason: Elevating the extremity is not the first nursing action that the nurse should perform, as it may decrease blood flow and increase tissue ischemia in compartment syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: Loss of erythropoietin will not result in diminished immunologic function, but it may affect the production of some white blood cells and antibodies.
Choice B Reason: Loss of erythropoietin will not result in hypertension, but it may cause hypotension due to reduced blood volume and viscosity.
Choice C Reason: Loss of erythropoietin will not result in elevated lipid levels in the bloodstream, but it may be associated with dyslipidemia due to other factors such as malnutrition, inflammation, or medication use.
Choice D Reason: Loss of erythropoietin will result in anemia, as erythropoietin is a hormone that stimulates the bone marrow to produce red blood cells.
Correct Answer is D
Explanation
Choice A Reason: Administering antispasmodic medications is not the first action that the nurse should perform, as it may not resolve the problem of urinary output or irrigation flow.
Choice B Reason: Notifying the provider is not the first action that the nurse should perform, as it may delay the intervention and worsen the outcome.
Choice C Reason: Offering oral fluids is not the first action that the nurse should perform, as it may increase fluid overload or bladder pressure.
Choice D Reason: Determining the patency of the tubing is the first action that the nurse should perform, as it may identify and correct any obstruction or kinking that prevents urinary output or irrigation flow.
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