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
Having the patient lift their back and buttocks using a trapeze allows for proper assessment of pressure areas and skin care. This technique reduces the risk of further injury or discomfort and provides better access for the nurse to assess the skin condition.
Choice B rationale
Asking the patient to turn to the side independently may not be feasible for a patient with a pelvic fracture. This method can cause pain and risk further injury, making it an unsuitable choice for assessing pressure areas.
Choice C rationale
Rolling the patient over to the side by pushing on the patient's hip is not recommended as it can exacerbate the injury and cause pain. This method is not appropriate for patients with pelvic fractures.
Choice D rationale
Deferring back assessment until the patient is ambulatory is not a safe practice. Pressure areas should be regularly assessed to prevent skin breakdown and complications, even if the patient is not yet ambulatory.
Correct Answer is D
Explanation
Choice A rationale
Reduced bronchospasm is a beneficial outcome for COPD, but it is not the primary outcome related to gas exchange.
Choice B rationale
Decreased breathlessness is a positive outcome for COPD, but it is not directly related to gas exchange.
Choice C rationale
Increased carbon dioxide retention is a negative outcome and indicates worsening of gas exchange.
Choice D rationale
Improved oxygen saturation levels are a direct and measurable outcome of effective gas exchange and indicate better oxygenation in COPD patients.
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