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: Side lying on the affected eye is not the correct position for the client after cataract surgery, as it may increase intraocular pressure and cause bleeding or damage to the surgical site.
Choice B Reason: Supine is not the correct position for the client after cataract surgery, as it may cause fluid accumulation and swelling in the eye.
Choice C Reason: Prone is not the correct position for the client after cataract surgery, as it may cause pressure and friction on the eye.
Choice D Reason: Semi Fowler's is the correct position for the client after cataract surgery, as it helps to reduce intraocular pressure and promote drainage and healing of the eye.
Correct Answer is A
Explanation
Choice A Reason: Determining the client's calcium level is the appropriate action for the nurse to take, as it may indicate hypocalcemia, which is a possible complication of thyroidectomy due to accidental removal or damage of the parathyroid glands. Hypocalcemia can cause muscle spasms, tingling, numbness, or tetany.
Choice B Reason: Monitoring the client's peripheral pulses is not the appropriate action for the nurse to take, as it does not address the cause of muscle spasms or provide any relief.
Choice C Reason: Administering IV normal saline solution is not the appropriate action for the nurse to take, as it does not correct hypocalcemia or prevent further complications.
Choice D Reason: Giving the client an oral potassium supplement is not the appropriate action for the nurse to take, as it may worsen hypocalcemia or cause hyperkalemia, which can affect cardiac function and muscle contraction.
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