Exhibits

The nurse is preparing to discharge the client. Which of the following statements by the client indicates an understanding of the discharge teaching? Select all that apply.

Rationale:

A. Maintain the head of the client's bed at a 30° angle or higher: Elevating the head of the bed reduces the risk of aspiration by preventing gastric contents from entering the airway, especially during and after feeding.

B. Check gastric residuals every 4 hr: Regular residual checks help assess gastric emptying and tolerance of enteral feeding. High residuals may indicate delayed gastric motility and require intervention.

C. Check placement of the feeding tube by x-ray once daily: An x-ray is used only once to confirm initial tube placement. Daily x-rays are unnecessary unless dislodgement is suspected; routine placement verification is done via pH testing or aspiration.

D. Ensure the formula is cold before administration: Cold formula can cause cramping or discomfort. It should be at room temperature before administration to promote tolerance and reduce gastrointestinal side effects.

E. Change the feeding container and tubing every 24 hr: Changing feeding equipment every 24 hours prevents microbial contamination, especially with continuous feeding, and is consistent with infection control guidelines.

Rationale for Correct Choices:

• Compartment syndrome: The client shows hallmark signs: pain unrelieved by medication (rated 9/10), cool foot, 2+ edema, numbness, absent pedal pulses, delayed capillary refill, and inability to move the foot. These findings indicate increased pressure within a muscle compartment that compromises circulation and nerve function, requiring emergency intervention to prevent tissue necrosis or amputation.
• Osteomyelitis: A rapidly rising temperature (up to 38.9°C), elevated WBC count (28,000/mm³), and presence of drainage from the splint site suggest a localized bone infection. Osteomyelitis can develop from an open fracture, especially post-surgery, and early detection is critical for avoiding systemic infection or bone destruction.

Rationale for Incorrect Choices:

• Deep vein thrombosis (DVT): While immobilization increases DVT risk, the scenario lacks classic signs like unilateral calf swelling, warmth, erythema, or a positive Homan's sign. Additionally, pulses are absent in the foot, not consistent with a DVT presentation, which typically does not affect distal pulses.
• Fat embolism: The client does not exhibit hallmark signs such as acute respiratory distress, petechial rash, or altered mental status. Although long bone fractures pose a fat embolism risk, no findings suggest embolic movement or pulmonary compromise in this case.