A nurse is caring for a client who has a full arm cast and reports a pain level of 8 on a scale of 0 to 10, which is unrelieved by pain medication.
Which of the following actions should the nurse plan to take first?

Check the circulation of the affected extremity.

Administer additional pain medication.

Reposition the affected extremity.

Document the findings.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Checking the circulation of the affected extremity is crucial because the greatest risk to the client is neuromuscular injury resulting from compartment syndrome. Compartment syndrome is a serious condition that occurs when there’s increased pressure within the muscles, leading to decreased blood flow, which can cause muscle and nerve damage. Early detection and intervention are essential to prevent permanent damage.

Choice B rationale

Administering additional pain medication might provide temporary relief, but it does not address the underlying issue of potential compartment syndrome. Pain unrelieved by medication is a key indicator of this condition, and addressing circulation is the priority.

Choice C rationale

Repositioning the affected extremity might help with comfort, but it does not address the potential for compartment syndrome. The primary concern is ensuring adequate blood flow to prevent tissue damage.

Choice D rationale

Documenting the findings is important for medical records, but it does not address the immediate risk of compartment syndrome. Immediate action to check circulation is necessary to prevent serious complications.

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Correct Answer is A

Explanation

Choice A rationale

The ability to comply with anticoagulant therapy for life is essential for clients undergoing mechanical valve replacement. Mechanical valves are prone to thrombus formation, which can lead to serious complications such as stroke. Therefore, lifelong anticoagulation therapy is necessary to prevent clot formation on the valve.

Choice B rationale

While body image problems may arise due to surgical scars or the presence of a mechanical valve, they are not a primary concern that needs to be assessed before surgery. The focus should be on the client’s ability to manage the medical requirements post-surgery.

Choice C rationale

The physical demands of the client’s lifestyle are important but not as critical as the ability to comply with anticoagulant therapy. The primary concern is ensuring the client can adhere to the necessary medical regimen to prevent complications.

Choice D rationale

Participation in a cardiac rehabilitation program is beneficial for recovery and improving cardiovascular health, but it is not as crucial as the ability to comply with anticoagulant therapy. The main priority is preventing thrombus formation on the mechanical valve.

A. Serosanguineous drainage. B. Mild erythema. C. Warmth. D. Fever.

Correct Answer is D

Explanation

Choice A rationale

Serosanguineous drainage is a normal finding at pin sites and does not indicate infection. It is a mixture of serum and blood and is expected during the initial healing phase.

Choice B rationale

Mild erythema around the pin sites can be a normal inflammatory response and does not necessarily indicate infection. It is important to monitor for other signs of infection.

Choice C rationale

Warmth at the pin sites can be a normal finding due to increased blood flow during the healing process. However, it should be monitored in conjunction with other signs of infection.

Choice D rationale

Fever is a systemic sign of infection and indicates that the body is responding to an infectious process. It is a critical finding that requires prompt attention and intervention.

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A nurse is caring for a client who has a full arm cast and reports a pain level of 8 on a scale of 0 to 10, which is unrelieved by pain medication. Which of the following actions should the nurse plan to take first?

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A nurse is caring for a client who has a full arm cast and reports a pain level of 8 on a scale of 0 to 10, which is unrelieved by pain medication.
Which of the following actions should the nurse plan to take first?