A client with a right arm cast is experiencing signs of a serious complication. Which of the following would cause the nurse the most concern?
1. Capillary refill time less than 3 seconds
2. Finger movement
3. Itching under the cast
4. Severe pain to the right arm continues after receiving pain medication
4
Severe pain that continues after receiving pain medication would be considered as being disproportionate to the injury, can be a sign of compartment syndrome, and should be immediately reported. The other options are expected assessment findings for a client with a cast.
You might also like to view...
The nurse analyzes the results of a patient's arterial blood gases (ABGs). Which finding would require immediate action?
a. The bicarbonate level (HCO3–) is 31 mEq/L. b. The arterial oxygen saturation (SaO2) is 92%. c. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg. d. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.
The nurse is caring for a 2-hour-old newborn whose mother is diabetic. The nurse assesses that the newborn is experiencing tremors. Which nursing action has the highest priority?
1. Obtain a blood calcium level. 2. Take the newborn's temperature. 3. Obtain a bilirubin level. 4. Place a pulse oximeter on the newborn.
The nurse is caring for a thin-framed adult who is scheduled to receive multiple doses of antineoplastic medication. The nurse should expect the dosage for this person to be:
a. lower than normal. b. higher than normal. c. divided in half. d. unchanged.
A nurse planning care for a patient who has somatoform disorder needs to be aware that these patients often have relationship problems associated with:
a. anger. b. dependency. c. detachment. d. misplaced objectivity.