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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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Engage in repetitive tasks, even when joints are inflamed, to keep the joints mobile is not recommended; rest and joint protection are important during inflammation.

B. Press water from a sponge rather than wringing it is a good strategy to avoid straining the joints.

C. Finish weekly household tasks within 1 or 2 days may lead to increased stress on the joints; tasks should be spread out to avoid exacerbating symptoms.

D. Turn doorknobs using a clockwise motion does not have specific benefits for managing rheumatoid arthritis; using adaptive devices is generally recommended.

A. Obtain a cardiology consult. B. Perform pre-oxygenation prior to suctioning. C. Administer an antidysrhythmic medication. D. Suction the client less frequently.

Correct Answer is B

Explanation

A. Obtain a cardiology consult is not an immediate action for an irregular heart rate during suctioning; it is a more long-term consideration.

B. Perform pre-oxygenation prior to suctioning is the correct action to prevent hypoxia, which can cause increased heart rate and irregular rhythms during suctioning.

C. Administer an antidysrhythmic medication is not appropriate for the immediate concern of heart rate changes during suctioning.

D. Suction the client less frequently does not address the acute problem of the irregular heart rate; pre-oxygenation before suctioning is more relevant.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has rheumatoid arthritis about self-care strategies for managing the disease. Which of the following activities should the nurse include in the teaching?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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