The nurse is caring for a client who sustained a crushed injury to the lower extremity and has developed compartment syndrome. What intervention should the nurse plan for next?
Insertion of central venous access
Phlebotomy
Fasciotomy
Insertion of arterial line
The Correct Answer is C
A. Insertion of central venous access: This is not relevant to compartment syndrome management. Central venous access is used for fluid administration or monitoring central venous pressure.
B. Phlebotomy: This is unrelated to the management of compartment syndrome, as it involves drawing blood and does not address the increased pressure.
C. Fasciotomy: Compartment syndrome is a medical emergency where increased pressure within a closed compartment compromises circulation and tissue function. A fasciotomy involves surgically opening the compartment to relieve the pressure, prevent tissue necrosis, and save the limb. This is the definitive treatment.
D. Insertion of arterial line: While this may be useful for monitoring blood pressure in critical situations, it does not relieve compartment syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Pelvic fracture: Pelvic fractures may cause significant pain and instability but do not typically result in a shortened, adducted, and externally rotated leg.
B. Femoral neck fracture: These findings (shortened, adducted, externally rotated leg) are classic for a femoral neck fracture due to muscle contraction and displacement of the bone.
C. Tibia fracture: Tibia fractures typically present with swelling and deformity, not shortening or rotation of the leg.
D. Fibula fracture: A fibula fracture alone rarely causes leg shortening or rotation as it is a non-weight-bearing bone.
Correct Answer is A
Explanation
A. Auscultate for a pericardial friction rub: These symptoms are classic for pericarditis, a complication of MI. A pericardial friction rub is a key diagnostic finding.
B. Inspect the skin for petechiae: Petechiae are associated with conditions like infective endocarditis or thrombocytopenia, not pericarditis.
C. Palpate the radial pulses bilaterally: Assessing radial pulses is essential for circulation but does not directly relate to pericarditis symptoms.
D. Assess for abdominal pain: Abdominal pain is not typical of pericarditis and would not be the priority assessment.
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