A client with a right ulnar fracture and cast placement reports an increase in arm pain. Which action should the nurse take next?
Implement distraction techniques.
Assess right radial pulse volume.
Administer a PRN analgesic.
Measure the blood pressure.
The Correct Answer is B
B. An increase in pain after cast placement could indicate complications such as compartment syndrome, which is a serious condition that occurs when increased pressure within a confined space (such as the area within the cast) compromises circulation and tissue perfusion. Assessing the radial pulse volume on the affected arm is crucial to evaluate perfusion distal to the fracture site.
A. Distraction technique may help manage the client's pain but does not address the underlying cause of the pain increase, which could be related to compromised circulation.
C. Analgesics relieve pain but do not address the immediate limb threatening issue at hand.
D. Measuring blood pressure is not directly related to assessing circulation distal to the fracture site.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Tidaling is an expected finding in a functioning chest drainage system and indicates proper drainage of air or fluid from the pleural space. Continuously monitoring the drainage system allows the nurse to assess the volume, color, and consistency of drainage.
A. Rising water levels during inspiration and falling during expiration are indicative of proper chest tube function, therefore, auscultation for breath sounds may not provide additional relevant information related to the functioning of the chest tube.
C. Performing this action unnecessarily may disrupt the functioning of the drainage system and should only be done if specifically instructed by the healthcare provider.
D. While it is important to monitor for leaks, the observation of tidaling in the water-seal chamber does not necessarily indicate a leak at the insertion site.
Correct Answer is B
Explanation
B. Lactulose works by acidifying the colonic contents, which promotes the conversion of ammonia (NH3) to ammonium (NH4+). Ammonium is less readily absorbed from the colon into the bloodstream, reducing systemic ammonia levels. This action helps alleviate the neurotoxic effects of ammonia on the brain, thereby improving neurological symptoms associated with hepatic encephalopathy.
A. Lactulose is required in clients with hepatic encephalopathy to excrete ammonia lowering its levels in blood. Holding the lactulose dose is inappropriate as the client’s ammonia levels are still high
C. Rehydrating the clients to replace lost fluids in the loose stools is important but does not address
the client’s elevated ammonia levels which may be exacerbating the client’s encephalopathy.
D. Reporting the number of diarrhea stools to the healthcare provider is important for ongoing assessment and management of the client's condition. However, it does not address the clients high ammonia levels.
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