A nurse is caring for a client diagnosed with a fractured left tibia and fibula. Which data should the nurse report to the healthcare provider immediately?

Localized edema and discoloration occurring hours after the injury

Pain relieved after taking 4 mg of hydromorphone

Pedal pulses cannot be located with a Doppler and complaints of increasing pain

Generalized weakness and pain at the site of injury

Answer and Explanation

The Correct Answer is C

A. Localized edema and discoloration are expected findings after a fracture and do not typically require immediate reporting unless they are accompanied by signs of compartment syndrome or other complications.

B. Pain relieved by hydromorphone indicates that the pain is being effectively managed. This does not require immediate reporting to the healthcare provider.

C. The absence of pedal pulses, even with the use of a Doppler, combined with increasing pain, is a critical finding that suggests compromised circulation, possibly due to compartment syndrome. This is a medical emergency requiring immediate intervention to prevent permanent tissue damage or loss of the limb.

D. Generalized weakness and pain at the site of injury are common findings after a fracture and do not indicate an urgent complication unless associated with other concerning symptoms.

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Correct Answer is C

Explanation

A. While ensuring that a client with an inguinal hernia voids before discharge is important, it does not warrant immediate intervention unless there are signs of urinary retention or other complications.

B. Refusing to deep breathe after an open cholecystectomy can increase the risk of postoperative complications like atelectasis, but it does not require immediate intervention unless there are signs of respiratory distress or infection.

C. Pain on inspiration in a client with deep vein thrombosis (DVT) is a potential sign of pulmonary embolism (PE), a life-threatening complication. Immediate assessment and intervention are critical to prevent further deterioration.

D. Refusing to turn for three hours increases the risk of pressure injuries, but this is not as urgent as the potential for a pulmonary embolism. The nurse should address this issue promptly but not before assessing the client with possible PE.

A. A condition in which the ribs are fractured in multiple places, resulting in a segment of the chest wall that moves independently during respiration B. A condition in which the chest wall is paralyzed, resulting in difficulty breathing C. A condition in which the lungs are unable to fully expand, resulting in decreased oxygenation D. A condition in which the diaphragm becomes weak, resulting in decreased lung expansion

Correct Answer is A

Explanation

A. Flail chest occurs when multiple ribs are fractured in more than one location, creating a free-floating segment of the chest wall. This segment moves paradoxically during respiration, meaning it moves inward during inspiration and outward during expiration, which impairs effective breathing and oxygenation.

B. Paralysis of the chest wall may occur in conditions like spinal cord injuries but is not the defining characteristic of flail chest.

C. While decreased oxygenation can occur with flail chest due to impaired ventilation, the defining feature is the paradoxical movement of the fractured rib segment.

D. Weakness of the diaphragm can impair lung expansion, but this is characteristic of conditions like diaphragmatic paralysis, not flail chest.

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A nurse is caring for a client diagnosed with a fractured left tibia and fibula. Which data should the nurse report to the healthcare provider immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment data would warrant immediate intervention by the nurse?

Correct Answer is C

Explanation

A patient is admitted to the respiratory unit with flail chest. The nurse understands that a flail chest is:

Correct Answer is A

Explanation

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