Twelve hours after experiencing a traumatic closed fracture of the lower left tibia, a client reports pain, tingling, and diminished toe movement in the left foot. Which nursing problem has the highest priority based on this information?
Impaired comfort.
Impaired skin integrity.
Risk for infection related to traumatic fracture.
Risk for peripheral neurovascular dysfunction.
The Correct Answer is D
A. While impaired comfort is a concern, the priority is to address potential neurovascular compromise.
B. Impaired skin integrity is a concern but not the most immediate issue given the symptoms described.
C. Risk for infection is important but secondary to the acute concern of neurovascular function.
D. Risk for peripheral neurovascular dysfunction is the highest priority as it indicates potential compartment syndrome or other serious complications requiring urgent intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","F"]
Explanation
A. Attach the client to a cardiorespiratory monitor to measure the respiratory rate: The respiratory rate is within the normal range and does not require continuous monitoring at this stage unless other symptoms suggest deterioration.
B. Assure that the blood pressure cuff is the right size: The blood pressure is within normal limits and does not indicate an issue with the cuff size at this moment.
C. Alert the healthcare provider once the abnormal finding is confirmed: A temperature of 102.1° F (38.9° C) is a significant fever and could indicate worsening infection or an adverse reaction to the medication. Alerting the healthcare provider is essential for prompt evaluation and treatment adjustment.
D. Retake the temperature orally: Confirming the elevated temperature with a retake is crucial for accuracy. Temperature readings can sometimes be affected by factors like improper thermometer use or external influences.
E. Reassess the blood pressure: Blood pressure readings are stable and not indicative of any immediate issue requiring reassessment.
F. Measure the heart rate for a full 60 seconds: The heart rate of 62 beats/minute is on the lower side of normal, and measuring for a full minute will provide a more accurate assessment of the client’s heart rate and detect any irregularities.
Correct Answer is D
Explanation
A. Scarlet fever and pneumonia do not require airborne precautions; they are primarily spread through respiratory droplets.
B. Scabies is a skin infestation that requires contact precautions, not airborne precautions.
C. Herpes simplex II lesions require contact precautions and are not airborne.
D. A positive Mantoux test and sputum cultures positive for acid-fast bacillus indicate tuberculosis, which requires airborne precautions, including a negative airflow room and the use of a particulate respirator mask.
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