A nurse in an emergency department is caring for a 60-year-old client.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

1. Condition: Acute Compartment Syndrome

Justification: The presence of severe pain, swelling, numbness, and a weak radial pulse along with delayed capillary refill are classic signs of acute compartment syndrome. Immediate surgical intervention (fasciotomy) is necessary to relieve the pressure within the muscle compartments.

2. Actions to Take

Prepare for Fasciotomy:

Justification: This surgical procedure will relieve the internal pressure causing the symptoms.

Request Prescription for Pain Medication:

Justification: Adequate pain management is important for client comfort and can also indicate response to treatment.

3. Parameters to Monitor

Neurovascular Status:

Justification: Monitoring for further deterioration of symptoms such as worsening numbness or weak pulses is essential.

WBC Count:

Justification: Helps in the broader assessment of possible infection, though not directly related to acute compartment syndrome

Nursing Test Bank

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Correct Answer is ["A","B","D"]

Explanation

Decreased Lung Sounds: Could indicate complications such as pneumothorax.

Heart Rate 110/min: Tachycardia may suggest a reaction to recent procedures or other underlying issues.

Subcutaneous Emphysema: Indicates possible air leakage that needs to be addressed.

Does Not Require Immediate Follow-Up:

Oxygen Saturation of 95%: Indicates acceptable oxygenation status.

Trachea Midline: Shows that there is no mediastinal shift.

Puncture Site Dry: Indicates that there is no ongoing issue at the insertion site

A. Irregular pulsations B. Bounding pulsations C. Tachycardia D. Bradycardia

Correct Answer is A

Explanation

A. Irregular pulsations are expected with PVCs because they cause occasional early beats that disrupt the regular rhythm of the pulse.

B. Bounding pulsations are not specific to PVCs and are more indicative of conditions like high cardiac output states.

C. Tachycardia is not a direct finding associated with PVCs; PVCs are more about irregular beats rather than a consistently high heart rate.

D. Bradycardia is not typically associated with PVCs; PVCs are characterized by irregular beats but not necessarily a slow heart rate.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 75-year-old male client who is experiencing difficulty breathing and shortness of breath. Exhibits The nurse is caring for the client following a thoracentesis. (Select the 3 findings that require immediate follow-up.)

Correct Answer is ["A","B","D"]

Explanation

A nurse on a telemetry unit is caring for a client who has premature ventricular contractions (PVCs). While sitting in a chair, the client reports feeling lightheaded. If the client is having PVCs, which of the following findings should the nurse expect when auscultating the client's apical pulse?

Correct Answer is A

Explanation

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