A patient with a long leg cast reports pain in the toes. The nurse discovers that the toes are pale and cool to the touch with intact pulses and minimal neuropathy. The findings indicate that the patient may be experiencing which complications?

A fat embolism

Osteomyelitis

Compartment syndrome

A pressure ulcer

Answer and Explanation

The Correct Answer is C

A. A fat embolism typically presents with respiratory distress, altered mental status, and petechial rash, not the symptoms of pale and cool toes with intact pulses. It is unlikely to cause localized pain in the toes alone.
B. Osteomyelitis is an infection of the bone and would not cause the pale, cool appearance of the toes in this scenario. Symptoms of osteomyelitis include fever, localized pain, and swelling, but it does not present with the same vascular and neurovascular changes as compartment syndrome.
C. Compartment syndrome occurs when there is increased pressure within a muscle compartment, leading to reduced blood flow. The symptoms of pale, cool toes with pain and intact pulses are indicative of impaired circulation due to increased pressure, which is a hallmark of compartment syndrome. This is a medical emergency that requires prompt intervention.
D. A pressure ulcer typically presents with localized skin damage due to prolonged pressure, but it would not cause pale, cool toes or pain in the way compartment syndrome would.

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Correct Answer is B

Explanation

A. Heparin should not be discontinued immediately after starting warfarin, as warfarin takes several days to reach therapeutic levels. Discontinuing heparin too early could put the client at risk for clotting.
B. Warfarin takes several days to reach a therapeutic effect, so heparin is continued initially to provide immediate anticoagulation until the warfarin becomes effective.
C. Heparin does not increase the effects of warfarin, but both medications are used together temporarily to ensure adequate anticoagulation until warfarin reaches therapeutic levels.
D. Neither heparin nor warfarin dissolves clots. They are anticoagulants that prevent further clot formation, not thrombolytics that break down existing clots.

A. Ensure adequate nutrition. B. Prevent aspiration. C. Relieve the client's pain. D. Promote oral hygiene

Correct Answer is B

Explanation

A. Ensuring adequate nutrition is important, but the priority is preventing aspiration, as the client may have difficulty swallowing or clearing the airway due to the intermaxillary fixation. Aspiration could lead to serious complications like pneumonia.
B. Preventing aspiration is the priority because the client may have difficulty swallowing or controlling their airway due to the surgical procedure and fixation of the jaw. The nurse should ensure the client's airway is clear and that they are positioned appropriately to prevent aspiration.
C. Pain relief is important for comfort and recovery, but it is secondary to ensuring the client's airway is protected and preventing aspiration, which could lead to more severe complications.
D. Promoting oral hygiene is important, but it is not the priority in the immediate postoperative period. The focus should be on ensuring the airway is clear and preventing aspiration, especially if the client is unable to properly swallow or manage secretions.

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A patient with a long leg cast reports pain in the toes. The nurse discovers that the toes are pale and cool to the touch with intact pulses and minimal neuropathy. The findings indicate that the patient may be experiencing which complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take?

Correct Answer is B

Explanation

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