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 C
Explanation
Choice A rationale
Hypertension is not a typical finding associated with community-acquired pneumonia. The condition more commonly presents with respiratory symptoms such as cough, fever, and difficulty breathing.
Choice B rationale
Unequal pupils are not a common finding in community-acquired pneumonia and could indicate a neurological issue or head injury, which would require further investigation.
Choice C rationale
Confusion, particularly in older adults, can be a symptom of community-acquired pneumonia. It is often due to hypoxia or systemic inflammation and is a sign of a more severe infection.
Choice D rationale
Tympany upon chest percussion is not expected in pneumonia. Pneumonia typically presents with dullness on percussion due to the consolidation of lung tissue, not the hyperresonance that causes tympany.
Correct Answer is A
Explanation
Choice A rationale
Using the inhaler before engaging in physical activity helps to prevent exercise-induced bronchospasm, which is common in patients with COPD.
Choice B rationale
Skipping doses if symptoms improve is not recommended as it can lead to suboptimal control of COPD and potential exacerbations.
Choice C rationale
Using the inhaler only when experiencing severe symptoms is not effective in managing COPD. Regular use as prescribed helps maintain lung function and prevent exacerbations.
Choice D rationale
Doubling the dose if symptoms do not improve immediately is not safe and can lead to adverse effects. Patients should follow the prescribed dosage and consult their healthcare provider if symptoms persist.
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