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: Buffalo hump and moon face are physical assessment findings that the nurse would expect to observe in a client with Cushing's syndrome, as they indicate fat redistribution and accumulation due to excess cortisol production.
Choice B Reason: Dry, scaly skin and cold intolerance are not physical assessment findings that the nurse would expect to observe in a client with Cushing's syndrome, but they may indicate hypothyroidism, which affects the metabolism and skin condition.
Choice C Reason: Dry, sticky mucous membranes and hypovolemia are not physical assessment findings that the nurse would expect to observe in a client with Cushing's syndrome, but they may indicate dehydration or diabetes insipidus, which affect the fluid balance and urine output.
Choice D Reason: Exophthalmos and tachycardia are not physical assessment findings that the nurse would expect to observe in a client with Cushing's syndrome, but they may indicate hyperthyroidism, which affects the eye protrusion and heart rate.
Correct Answer is D
Explanation
Choice A Reason: Compressing the nares is not the first action that the nurse should take, as it may increase intracranial pressure and worsen the head injury.
Choice B Reason: Administering decongestant for postnasal drip is not the first action that the nurse should take, as it may mask the signs of cerebrospinal fluid (CSF) leakage and delay diagnosis and treatment.
Choice C Reason: Tilting the head back is not the first action that the nurse should take, as it may cause aspiration of CSF or blood and increase the risk of infection.
Choice D Reason: Collecting the drainage is the first action that the nurse should take, as it helps to identify if the drainage is CSF or nasal secretions, and to monitor the amount and characteristics of the drainage.
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