A patient who had open reduction and internal fixation (ORIF) of left lower leg fractures continues to report severe pain in the leg 15 minutes after receiving the prescribed IV morphine.
The nurse determines pulses are faintly palpable and the foot is cool to the touch.
Which action should the nurse take next?
Check the patient's blood pressure.
Notify the health care provider.
Assess the incision for redness.
Reposition the left leg on a pillow.
The Correct Answer is B
Choice A rationale
Checking the blood pressure is not the priority action in this case. The symptoms described may suggest compartment syndrome, which is a medical emergency and requires immediate intervention.
Choice B rationale
The correct action is to notify the health care provider immediately as this may indicate compartment syndrome, a serious complication that can occur after fractures and can lead to permanent damage if not treated promptly.
Choice C rationale
Assessing the incision for redness is not appropriate in this scenario as the symptoms suggest a more severe underlying issue such as compartment syndrome, which requires urgent attention.
Choice D rationale
Repositioning the leg may provide temporary relief but does not address the potential underlying issue of compartment syndrome. The priority is to notify the health care provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Dysuria, or painful urination, is a common symptom of acute cystitis (bladder infection). Clients with acute cystitis often report burning sensations during urination and frequent urges to urinate.
Choice B rationale
Nasal congestion is not a symptom associated with acute cystitis. It is more commonly related to respiratory conditions like colds or allergies.
Choice C rationale
Joint pain is not related to acute cystitis. Joint pain can be associated with various musculoskeletal or autoimmune conditions, but not typically with a bladder infection.
Choice D rationale
Shortness of breath is not a symptom of acute cystitis. This symptom is more relevant to respiratory or cardiovascular conditions, not bladder infections.
Correct Answer is B
Explanation
Choice B rationale
Potassium levels should be reviewed before administering furosemide. Furosemide is a loop diuretic that can cause significant potassium loss through increased urine output. Monitoring potassium is crucial to prevent hypokalemia, which can lead to cardiac arrhythmias and other serious complications.
Choice A rationale
Bicarbonate levels are not directly impacted by furosemide use and are less critical to review in this context. While they are important in assessing acid-base balance, they are not the primary concern when administering furosemide.
Choice C rationale
Phosphate levels are not typically affected by furosemide and are not the main focus before administration. Monitoring phosphate might be important in other scenarios, but it is not directly relevant here.
Choice D rationale
Carbon dioxide levels are more relevant to respiratory function and acid-base balance but are not directly impacted by furosemide. The focus should be on monitoring electrolytes, particularly potassium, to prevent complications from diuretic therapy.
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