A nurse is teaching a client who has a pelvic fracture about manifestations of fat embolism syndrome. The nurse should include which of the following findings as an early manifestation?

Swollen calf

Bradycardia

Hypertension

Tachypnea

Answer and Explanation

The Correct Answer is D

D. Tachypnea is a classic early manifestation of fat embolism syndrome. Fat emboli can travel to the lungs and obstruct blood flow, leading to respiratory distress and hypoxemia. Tachypnea is the body's response to hypoxemia, as it attempts to increase oxygen intake by breathing more rapidly.

A. Swelling of the calf can occur with conditions such as deep vein thrombosis (DVT), but it is not typically an early manifestation of fat embolism syndrome.

B. tachycardia is more commonly seen due to the body's response to decreased oxygen levels and increased demand on the cardiovascular system.

C. Hypertension is not typically associated with fat embolism syndrome. Instead, hypotension can occur due to decreased cardiac output and systemic vasodilation in severe cases of fat embolism syndrome.

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Correct Answer is ["A"]

Explanation

A. Protein-calorie malnutrition can lead to decreased tissue integrity and delayed wound healing, increasing the risk of pressure ulcer development due to compromised nutritional status.

B. Diabetes, especially when uncontrolled, can lead to poor circulation and neuropathy, which increases the risk of pressure ulcers. Hyperglycemia can also impair wound healing and compromise the immune response, further contributing to the risk.

C. Edema increases pressure on the skin and underlying tissues, impairing circulation and increasing the risk of pressure ulcers, especially in areas where there is constant pressure or friction against surfaces.

D. A client with postoperative delirium is not necessarily at risk of delirium.

E. A client post cardiac catheterization and already ambulating is not at risk of pressure sores

A. Continue to take vital signs every 15 minutes. B. Notify the anesthesia care provider (ACP). C. Increase the postoperative IV fluid rate. D. Administer oxygen therapy at 100% per mask.

Correct Answer is A

Explanation

A. Vital sign monitoring every 15 minutes is a standard practice in the postanesthesia care unit (PACU) to closely monitor the patient's hemodynamic status and response to anesthesia. However, in this scenario, the patient's blood pressure (BP) and other vital signs are within an acceptable range, and there are no signs of instability.

B. The patient's vital signs, including BP, pulse rate, and skin condition, are within normal limits. There are no indications of hemodynamic instability or adverse events.

C. There is no indication to increase the postoperative intravenous (IV) fluid rate based solely on the patient's stable vital signs and absence of signs of dehydration or hypovolemia. Increasing IV fluids without clinical indication may lead to fluid overload and potential complications.

D. The patient's oxygen saturation level is not provided in the scenario, and there are no signs or symptoms of respiratory distress or hypoxemia. Therefore, administering oxygen therapy at 100% per mask is not warranted at this time.

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A nurse is teaching a client who has a pelvic fracture about manifestations of fat embolism syndrome. The nurse should include which of the following findings as an early manifestation?

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Naxlex Comprehensive Predictor Exams

A nurse is providing care for four clients on a medical-surgical unit, Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select all that apply.)

Correct Answer is ["A"]

Explanation

A patient is admitted to the postanesthesia care unit (PACU) with a blood pressure (BP) 122/72 mm Hg. Thirty minutes after admission, the BP is 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate?

Correct Answer is A

Explanation

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