A nurse is assisting with the care of an adolescent.
Complete the following sentence by using the lists of options.
The adolescent is at risk for developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Rationale for Correct Options:
Compartment syndrome is a serious complication that can occur after a fracture, particularly of a long bone like the femur. It results from increased pressure within a muscle compartment, leading to decreased blood flow and potential tissue damage.
Edema of the toes suggests swelling, which may indicate increasing pressure within the affected limb. The adolescent is already reporting significant pain (7/10) and has required repeated doses of IV morphine, which may not be sufficient to relieve compartment syndrome pain (a key warning sign). If left untreated, compartment syndrome can cause nerve and muscle damage, ischemia, and even permanent disability.
Rationale for Incorrect Options:
Deep Vein Thrombosis (DVT): DVT is a risk with immobilization, but it usually presents with unilateral swelling, warmth, and pain in the affected limb, not just toe edema.
Fat Embolism Syndrome: This occurs due to fat globules entering circulation after a long bone fracture. Symptoms include respiratory distress, mental status changes, and petechiae, which are not present here.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Increased intake of green, leafy vegetables does not inherently increase the risk for injury in clients with thrombocytopenia. In fact, these vegetables can provide essential vitamins and nutrients. However, clients may need to monitor their intake of vitamin K if they are on anticoagulant therapy, but this does not directly correlate with injury risk related to thrombocytopenia.
B. Wears a face mask around others is a precautionary measure typically used to prevent infection, especially in immunocompromised clients. This action does not increase the risk for injury; instead, it helps protect the client from potential pathogens.
C. Uses a firm-bristled toothbrush increases the risk for injury in clients with thrombocytopenia. A firm-bristled toothbrush can cause gum irritation and bleeding due to low platelet counts, which can lead to prolonged bleeding and increase the risk of oral injuries. Soft-bristled toothbrushes are recommended to minimize the risk of bleeding.
D. Sleeps 8 to 10 hr per night is a healthy behavior that supports overall well-being and recovery. Adequate sleep can help the body heal and does not increase the risk for injury in clients with thrombocytopenia.
Correct Answer is ["A","C","E"]
Explanation
A. Obtain a large-bore IV catheter. A large-bore IV catheter (18-gauge or larger) is necessary for blood transfusion to allow for rapid administration and reduce the risk of hemolysis. The provider has already prescribed this intervention.
B. Explain to the client that transfusion reactions are not serious. This statement is inaccurate and misleading. While many transfusion reactions are mild, some can be life-threatening, such as hemolytic reactions or anaphylaxis. The nurse should educate the client about signs and symptoms of a transfusion reaction and instruct them to report any discomfort or unusual sensations immediately.
C. Ensure two nurses confirm the information on the blood label. Before administering blood, two nurses must verify the blood product against the client's identification band, medical record, and blood bank documentation to prevent transfusion errors.
D. Ensure the transfusion tubing is flushed with dextrose 5% in water. Blood products should only be administered with normal saline (0.9% sodium chloride) because dextrose-containing solutions can cause red blood cell hemolysis. The nurse should ensure the IV tubing is primed with normal saline before starting the transfusion.
E. Witness the client signing consent for transfusion. Informed consent is required before administering a blood transfusion. While obtaining consent is the provider’s responsibility, the nurse can witness the signing and ensure that the client understands the procedure.
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