A nurse is completing a neurovascular check for a client who had an open reduction internal fixation surgery. Which of the following findings should the nurse identify as possible manifestations of compartment syndrome? (Select all that apply)

Absence of pulse

Altered sensation of the toes

Cool skin

Pain relieved by narcotics

Capillary refill 1 second

Answer and Explanation

Correct Answer : A,B,C

The nurse should identify the absence of pulse, altered sensation of the toes, and cool skin as possible manifestations of compartment syndrome. Compartment syndrome is a serious condition that can occur following surgery or injury. It is characterized by increased pressure within a muscle compartment that can lead to decreased blood flow and nerve damage.

Pain relieved by narcotics and capillary refill of 1 second are not manifestations of compartment syndrome. Pain relieved by narcotics is a normal response to pain medication. A capillary refill of 1 second is within the normal range and does not indicate compartment syndrome.

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Correct Answer is C

Explanation

The first action the nurse should perform is to check the client's temperature. A headache and stiﬀ neck can be symptoms of meningitis, which is an inﬂammation of the membranes surrounding the brain and spinal cord. Meningitis can be caused by a bacterial or viral infection and is often accompanied by a fever. Checking the client's temperature can help determine if the client has a fever and if further evaluation for meningitis is necessary.

Obtaining a throat culture specimen is not the first action the nurse should take.

Performing a complete blood count is not the first action the nurse should take.

Administering an oral analgesic is not the first action the nurse should take.

A. Toes cool to touch B. Inability to move toes C. Pallor of the toes D. Edema of the toes

Correct Answer is D

Explanation

The nurse should expect to find edema of the toes first if the cast is too tight. A cast that is too tight can impede blood flow and cause swelling (edema) of the toes. If the nurse notices edema of the toes, they should report this finding to the provider and take appropriate action to prevent further complications.

Toes cool to touch may occur if the cast is too tight but this is not typically the first finding.

The inability to move toes may occur if the cast is too tight but this is not typically the first finding.

The pallor of the toes may occur if the cast is too tight but this is not typically the first finding.

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A nurse is completing a neurovascular check for a client who had an open reduction internal fixation surgery. Which of the following findings should the nurse identify as possible manifestations of compartment syndrome? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse at a community health clinic is caring for a client who reports a headache and stiﬀ neck. Which of the following actions should the nurse perform first?

Correct Answer is C

Explanation

A nurse is collecting data from a client following the application of a leg cast for the treatment of a fracture. Which of the following findings should the nurse expect to find first if the cast is too tight?

Correct Answer is D

Explanation

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