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 A
Explanation
Choice A Reason: Following a high-fiber diet to establish bowel regularity is an appropriate instruction for a client who has hemorrhoids, as it helps to soften stools and reduce straining and pressure on hemorrhoids.
Choice B Reason: Using a stimulant laxative to prevent constipation is not an appropriate instruction for a client who has hemorrhoids, as it may cause diarrhea, dehydration, or electrolyte imbalance.
Choice C Reason: Cleaning the anal area after bowel movements with alcohol-based wipes is not an appropriate instruction for a client who has hemorrhoids, as it may irritate, dry, or damage hemorrhoidal tissue.
Choice D Reason: Limiting the intake of fruit to prevent loose stools is not an appropriate instruction for a client who has hemorrhoids, as fruit is a good source of fiber and fluid that can help prevent constipation and hemorrhoids.
Correct Answer is C
Explanation
Choice A Reason: Lantus is not a type of insulin that can treat this client, as it is a long-acting insulin that has no peak effect and lasts for 24 hours.
Choice B Reason: NPH is not a type of insulin that can treat this client, as it is an intermediate-acting insulin that peaks in 6 to 8 hours and lasts for 12 to 18 hours.
Choice C Reason: Regular is a type of insulin that can treat this client, as it is a short-acting insulin that peaks in 2 to 4 hours and lasts for 6 to 8 hours. It can be used to correct high blood glucose levels and treat diabetic ketoacidosis (DKA), which is indicated by confusion, flushing, and acetone breath.
Choice D Reason: Lispro is not a type of insulin that can treat this client, as it is a rapid-acting insulin that peaks in 30 minutes and lasts for 3 to 5 hours. It can be used to cover meals or snacks but not to treat DKA.
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