A nurse is collecting data from a client who has a fractured left femur and is in skeletal traction. Which of the following findings should the nurse identify as an indication of fat emboli to report to the provider?
Ecchymosis of the thigh
Serous drainage at the pin site
Chest petechiae
Muscle spasms in the left leg
The Correct Answer is C
Choice A reason: This is an incorrect finding, because ecchymosis of the thigh, or bruising, is not a sign of fat emboli, but a sign of bleeding or hematoma formation due to the fracture or the traction. The nurse should monitor the size and color of the ecchymosis and report any changes to the provider.
Choice B reason: This is an incorrect finding, because serous drainage at the pin site, or clear fluid, is not a sign of fat emboli, but a sign of normal healing or infection. The nurse should assess the amount, color, and odor of the drainage and report any signs of infection, such as purulent drainage, redness, swelling, or pain, to the provider.
Choice C reason: This is the correct finding, because chest petechiae, or small red spots on the chest, are a sign of fat emboli, which are a rare but serious complication of long bone fractures. Fat emboli occur when fat globules from the bone marrow enter the bloodstream and travel to the lungs, causing respiratory distress, hypoxia, and pulmonary edema. The nurse should report any signs of fat emboli, such as chest petechiae, dyspnea, tachypnea, tachycardia, fever, or confusion, to the provider.
Choice D reason: This is an incorrect finding, because muscle spasms in the left leg, or involuntary contractions of the muscles, are not a sign of fat emboli, but a sign of pain, inflammation, or nerve injury due to the fracture or the traction. The nurse should administer analgesics and muscle relaxants as prescribed, and provide comfort measures, such as massage, ice, or elevation, to the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is a nonspecific finding, because a report of a severe headache can be caused by many factors, such as concussion, migraine, or tension. A headache alone is not an indication of a skull fracture.
Choice B reason: This is a specific finding, because clear fluid coming from the nares can indicate a cerebrospinal fluid (CSF) leak, which is a sign of a basilar skull fracture. CSF is the fluid that surrounds and protects the brain and spinal cord, and can leak through the nose or ears if the skull is fractured.
Choice C reason: This is a nonspecific finding, because a brief change in level of consciousness can be caused by many factors, such as hypoxia, hypoglycemia, or seizure. A change in level of consciousness alone is not an indication of a skull fracture.
Choice D reason: This is a nonspecific finding, because bleeding from the top of the scalp can be caused by many factors, such as laceration, abrasion, or contusion. Bleeding from the scalp alone is not an indication of a skull fracture.
Correct Answer is A
Explanation
Choice A reason: This is a correct statement, because checking the heart rate each day can help monitor the function and effectiveness of the pacemaker, and detect any signs of malfunction, such as bradycardia, tachycardia, or irregular rhythm.
Choice B reason: This is an incorrect statement, because the client still needs to take the antihypertensive medications as prescribed, even with a pacemaker. The pacemaker regulates the heart rate, but does not control the blood pressure, which can be affected by other factors, such as stress, diet, or kidney function.
Choice C reason: This is an incorrect statement, because the client should avoid stretching the arms above the head for the first few weeks after the pacemaker insertion, as it can cause dislodgment or damage to the pacemaker leads. The client should limit the arm movements and activities until the incision site heals and the provider approves.
Choice D reason: This is an incorrect statement, because the client can stand in front of a microwave oven without any risk, as long as the oven is in good working condition and does not leak radiation. The modern microwave ovens and pacemakers are designed to prevent any interference or damage. However, the client should avoid close contact with other sources of electromagnetic fields, such as metal detectors, cell phones, or MRI machines.
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