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: Impaired skin integrity is not the most appropriate nursing diagnosis for a client with Addison's disease, as it does not reflect the main problem of adrenal insufficiency and cortisol deficiency.
Choice B Reason: Fluid volume overload is not the most appropriate nursing diagnosis for a client with Addison's disease, as it does not reflect the main problem of adrenal insufficiency and aldosterone deficiency.
Choice C Reason: Imbalanced nutrition: more than body requirements is not the most appropriate nursing diagnosis for a client with Addison's disease, as it does not reflect the main problem of adrenal insufficiency and weight loss.
Choice D Reason: Risk for injury is the most appropriate nursing diagnosis for a client with Addison's disease, as it reflects the main problem of adrenal insufficiency and hypotension, which can cause falls, fainting, or shock.
Correct Answer is C
Explanation
Choice A Reason: Assisting the RN to prepare an IV insulin infusion is not the first action that the nurse should take, as it may not be appropriate for the client's condition without knowing the blood glucose level.
Choice B Reason: Giving the client 4 oz of orange juice is not the first action that the nurse should take, as it may worsen the client's condition if the blood glucose level is high.
Choice C Reason: Checking the client's capillary blood glucose is the first action that the nurse should take, as it helps to determine if the client has hyperglycemia or hypoglycemia and guides the appropriate intervention.
Choice D Reason: Assisting the RN to administer 50% dextrose is not the first action that the nurse should take, as it may be harmful for the client if the blood glucose level is high.
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