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 B

Explanation

A bounding distal pulse indicates impaired venous return in the aﬀected arm. A bounding pulse is a strong and forceful pulse that can be a sign of increased blood flow to the area. In this case, it may indicate that blood is not returning from the aﬀected arm as it should.

a. Auscultation of lungs revealing wheezing is not related to venous return in the aﬀected arm. Wheezing is a high-pitched whistling sound made while breathing and is usually a sign of a respiratory problem.

c. Fever is also not related to venous return in the aﬀected arm. Fever is an increase in body temperature and is usually a sign of an infection or inﬂammation.

d. Pain unrelieved by opioid analgesics is not an indication of impaired venous return in the aﬀected arm. Pain can have many causes and may not be relieved by opioid analgesics for various reasons.

A. Obtain a throat culture specimen. B. Perform a complete blood count. C. Check the client's temperature. D. Administer an oral analgesic.

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.

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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

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