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

The statement that clients in skin traction have more mobility than those in skeletal traction indicates that the newly licensed nurse understands these therapies. Skin traction is applied directly to the skin using splints, bandages, or adhesive tapes and is less invasive than skeletal traction³. Skeletal traction involves placing a pin, wire, or screw in the fractured bone and ataching weights to it to pull the bone into the correct position¹. Because skin traction is less invasive and does not involve inserting a pin into the bone, clients in skin traction have more mobility than those in skeletal traction.

a. Skeletal traction being better than skin traction for reducing a fracture is not necessarily true.

c. Skeletal traction having less risk for infection than skin traction is not true.

d. Clients in skin traction having more discomfort than those in skeletal traction is not necessarily true.

A. Monitor for elevated blood pressure. B. Provide analgesia for headaches. C. Prevent bladder distention. D. Elevate the client's head.

Correct Answer is C

Explanation

To prevent autonomic dysreﬂexia, the nurse should take the intervention of preventing bladder distention. Autonomic dysreﬂexia is a serious medical problem that can happen if a person has injured the spinal cord in their upper back¹. It makes their blood pressure dangerously high and can lead to a stroke, seizure, or cardiac arrest¹. One way to lower the chance of complications is to use the bathroom on a regular schedule and keep the bladder and bowels from becoming too full¹.

Monitoring for elevated blood pressure is important but not an intervention to prevent autonomic dysreﬂexia.

Providing analgesia for headaches is important but not an intervention to prevent autonomic dysreﬂexia.

Elevating the client's head is important but not an intervention to prevent autonomic dysreﬂexia.

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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 is discussing skeletal and skin traction with a newly licensed nurse. Which of the following statements should the nurse identify as an indication that the newly licensed nurse understands these therapies?

Correct Answer is B

Explanation

A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreﬂexia. Which of the following interventions should the nurse take to prevent autonomic dysreﬂexia?

Correct Answer is C

Explanation

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