The nurse is caring for a client who has a fractured tibia and is in a cast. Which of the following findings is a manifestation of compartment syndrome?
Redness and warmth of affected extremity
Slow capillary refill
Reduced level of consciousness
Pain and bleeding
The Correct Answer is B
Choice A Reason: Redness and warmth of affected extremity are not signs of compartment syndrome, but they may indicate other conditions such as infection or inflammation.
Choice B Reason: Slow capillary refill is a sign of compartment syndrome, as it indicates that there is impaired blood flow to the tissues due to increased pressure within the fascial compartment.
Choice C Reason: Reduced level of consciousness is not a sign of compartment syndrome, but it may indicate other serious conditions such as head injury, stroke, or hypoxia.
Choice D Reason: Pain and bleeding are not specific signs of compartment syndrome, but they may occur due to the fracture or other causes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: Compressing the nares is not the first action that the nurse should take, as it may increase intracranial pressure and worsen the head injury.
Choice B Reason: Administering decongestant for postnasal drip is not the first action that the nurse should take, as it may mask the signs of cerebrospinal fluid (CSF) leakage and delay diagnosis and treatment.
Choice C Reason: Tilting the head back is not the first action that the nurse should take, as it may cause aspiration of CSF or blood and increase the risk of infection.
Choice D Reason: Collecting the drainage is the first action that the nurse should take, as it helps to identify if the drainage is CSF or nasal secretions, and to monitor the amount and characteristics of the drainage.
Correct Answer is D
Explanation
Choice A Reason: Irrigating the fistula with 3 mL of normal saline solution is not a correct way to assess the patency of the fistula, as it may cause bleeding, infection, or dislodgement of the fistula.
Choice B Reason: Flushing the fistula with 1 mL of heparin solution once per shift is not a correct way to assess the patency of the fistula, as it may cause clotting, infection, or allergic reaction.
Choice C Reason: Infusing 50 mL of normal saline once per 24 hours is not a correct way to assess the patency of the fistula, as it may cause fluid overload, hypertension, or edema.
Choice D Reason: Palpating for a vibrating sensation at the fistula site is a correct way to assess the patency of the fistula, as it indicates that there is adequate blood flow through the fistula. This sensation is also known as a thrill.
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