How it Works
Try Naxlex NCLEX-RN (Free-Trial)

Exhibits

Specify which potential condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s response.

Answer and Explanation

The Correct Answer is []

  1. The client is most likely experiencing compartment syndrome, which is a condition where increased pressure within a closed space compromises blood flow and tissue perfusion. Compartment syndrome can occur after a fracture, especially if a cast or splint is applied too tightly. Some of the signs and symptoms of compartment syndrome are severe pain, paresthesia, pallor, and pulselessness.
  2. Two actions the nurse should take to address compartment syndrome are:
    • Elevate the extremity above the level of the heart to reduce swelling and improve venous return.
    • Remove the cast or loosen the dressing to relieve the pressure and restore blood flow. This may require notifying the physician or obtaining an order for bivalving or cutting the cast.
  3. Two parameters the nurse should monitor to assess the client’s condition are:
    • Capillary refill of the affected fingers, which should be less than 3 seconds. A prolonged capillary refill indicates poor perfusion and tissue ischemia.
    • Blood pressure of the client, which should be maintained within normal limits. Hypotension can worsen the perfusion deficit and lead to tissue necrosis.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is ["100"]

Explanation

To answer this question, we need to find the rate of infusion in milliliters per hour (mL/hr) that will deliver 1 liter (1000 mL) of 0.9% sodium chloride, USP intravenously (IV) over 10 hours. We can use the following formula to calculate the rate:

Rate(mL/hr)=Volume(mL)/Time(hr)

Plugging in the given values, we get:

Rate(mL/hr)=1000mL/10hr

Simplifying, we get:

Rate= 100mL/hr

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

Choice A reason: Place the client in a room near the elevator: This does **not** promote client safety, because it exposes the client to more noise and disturbance, which can increase stress and blood pressure. A quiet and calm environment is preferable for stroke clients.

Choice B reason: Complete a swallow study before giving anything by mouth: This **promotes** client safety, because it assesses the client's ability to swallow and prevent aspiration. Stroke clients may have impaired swallowing due to facial weakness or sensory loss.

Choice C reason: Provide a call button kept within reach: This **promotes** client safety, because it allows the client to communicate their needs and request assistance when needed. Stroke clients may have limited mobility or vision, which can increase their risk of falls or injuries.

Choice D reason: Initiate use of the bed alarm: This **promotes** client safety, because it alerts the staff if the client tries to get out of bed without assistance. Stroke clients may have impaired judgment or balance, which can lead to falls or accidents.

Choice E reason: Place client belongings out of reach: This does **not** promote client safety, because it makes the client feel frustrated and helpless. Stroke clients may have difficulty reaching for their belongings due to hemiparesis or hemiplegia, which can affect their self-care and independence. The nurse should place the client's belongings within reach on their unaffected side and encourage them to use them as much as possible.

Choice F reason: Instruct the client to call before getting up: This **promotes** client safety, because it ensures that the client has adequate support and supervision when getting up. Stroke clients may have orthostatic hypotension, which can cause dizziness or fainting when changing positions. The nurse should assist the client to get up slowly and monitor their vital signs.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register