A client who has sustained a crush injury to the right lower leg reports numbness and tingling of the affected extremity. The skin of the right leg appears pale. Which is the nurse's first interven-tion?
a. Assess pedal pulses.
b. Apply oxygen by nasal cannula.
c. Increase the IV flow rate.
d. Document the finding.
A
The symptoms represent early warning of acute compartment syndrome. In acute compartment syndrome, sensory deficits such as paresthesias precede changes in vascular or motor signs. If the nurse finds a decrease in pedal pulses, the health care provider should be notified as soon as possible.
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A young student is brought to the school nurse after falling off a swing. The nurse is documenting that the child has bruising on the lateral aspect of the right arm. What term will the nurse use to describe bruising on the skin in documentation?
A) Telangiectasias B) Ecchymoses C) Purpura D) Urticaria
Health care provider from a variety of disciplines in a community have noted a significant increase in cases of Chlamydia trachomatis
When planning health promotion and disease prevention interventions to combat this trend, nurses should recognize that the group at greatest risk of developing C. trachomatis infection is: A) Males between age 20 and 30 B) Women of childbearing age C) Teenage males who are sexually active D) Young women under the age of 25
Which symptoms in a client assist the nurse in confirming the diagnosis of pulmonary embolus (PE)? (Select all that apply.)
a. Wheezes throughout lung fields b. Hemoptysis c. Sharp chest pain d. Flattened neck veins e. Hypotension f. Pitting edema
The nurse's immediate action after the birth of a post-term infant with meconium stained amniotic fluid is to:
a. stimulate the infant to cry. b. suction the infant's airways. c. complete the 1- and 5-minute Apgars. d. vigorously dry the infant's head and trunk.