A nurse is replacing the dressing for a client who is postoperative following thoracic surgery.
When assessing the surgical wound, which of the following findings should the nurse identify as an indication of infection?

Choice A rationale

Encouraging the client to ambulate to the bathroom would be inappropriate and potentially harmful. The client is experiencing worsening pain, tingling, and is on a gurney en route to surgery for a fractured radius. Ambulation could exacerbate the injury, increase pain, and risk further complications. Mobility should be restricted until the fracture is stabilized and the client is post-operative.

Choice B rationale

This is the correct action as it assesses for potential complications of compartment syndrome, a critical and urgent condition. The worsening pain and tingling are classic symptoms. Compartment syndrome occurs when pressure builds within the fascial compartments, compromising circulation. A loss of peripheral pulses and delayed capillary refill are late signs of impaired circulation and are key indicators for this limb-threatening emergency.

Choice C rationale

Elevating the arm above the heart would decrease arterial blood flow to the injured extremity, which could worsen tissue perfusion and potentially lead to ischemia. For a client with a suspected circulatory compromise, such as with compartment syndrome, the arm should be kept at the level of the heart to maintain adequate blood flow.

Choice D rationale

Administering a sedative could mask the client's symptoms, particularly the level of pain and changes in mental status, which are crucial indicators of their deteriorating condition. The client's pain is a vital sign that needs to be continuously monitored, and sedation would hinder the nurse's ability to accurately assess for changes in their neurovascular status. .

Choice A rationale

Veracity is the ethical principle of telling the truth and being honest with clients. By informing the client about the potential side effect of lightheadedness while also clarifying that the procedure should not affect their memory, the nurse is providing accurate and complete information. This honesty allows the client to make an informed decision and builds trust in the therapeutic relationship. The nurse is being truthful about the known risks and benefits of the treatment.

Choice B rationale

Beneficence is the ethical principle of doing good and acting in the best interest of the client. While the nurse's actions are ultimately intended to be beneficial, the specific act of providing truthful information is a demonstration of veracity. Beneficence would involve ensuring the treatment is appropriate and safe for the client, whereas veracity is the specific communication of the truth about that treatment's effects.

Choice C rationale

Autonomy is the ethical principle that respects a client's right to self-determination and to make their own decisions. While providing truthful information supports the client's ability to exercise their autonomy, the act of giving the information itself is an example of veracity. The nurse is upholding the client's autonomy by being truthful, but the action of being truthful is the core principle demonstrated.

Choice D rationale

Fidelity is the ethical principle of keeping promises and being loyal to the client. This involves maintaining professional commitments and a trusting relationship. While providing accurate information contributes to a trusting relationship, it is a direct fulfillment of the duty of veracity. Fidelity is more about honoring commitments and promises, which is a broader concept than simply telling the truth about a procedure's effects. *.