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 B

Explanation

A. The visibility of the eyelets on the chest tube is not a critical indicator for immediate notification unless other issues are present.
B. Movement of the trachea toward the unaffected side can indicate tension pneumothorax or other significant issues requiring immediate intervention.
C. Crepitus around the insertion site can indicate subcutaneous emphysema, which may be a complication but not an immediate emergency.
D. Bubbling in the water seal chamber during exhalation is a normal finding, as it indicates that the chest tube is functioning to allow air to escape.

A. Hypotension B. Bone pain C. Bradypnea D. Slurred speech E. Pruritus

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

Explanation

A. Hypotension is not typically associated with ESRD; hypertension is more common due to fluid retention and alterations in renin-angiotensin system.
B. Bone pain is common in ESRD due to disturbances in calcium and phosphate metabolism, leading to renal osteodystrophy.
C. Bradypnea is not an expected finding; however, patients may exhibit Kussmaul respirations if they have metabolic acidosis.
D. Slurred speech is a typical finding in ESRD.
E. Pruritus is a common symptom in ESRD due to the buildup of uremic toxins and alterations in calcium and phosphate metabolism.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

Correct Answer is B

Explanation

A nurse is caring for a client who has end-stage renal disease (ESRD). Which of the following are expected findings? (Select all that apply).

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

Explanation

A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate?

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?

A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a myocardial infarction? (Select all that apply.)

A nurse is teaching an assistive personnel (AP) about the purpose of a footplate on the bed of a client whose leg is in Buck's traction. Which of the following statements indicates the AP understands the teaching?

A nurse in the ICU is caring for a client who has heart failure and is receiving a dobutamine drip. The nurse should identify that which of the following findings indicates that the medication is effective?

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