A 32-year-old patient who has had an open reduction and internal fixation (ORIF) of left lower leg fractures continues to complain of severe pain in the leg 15 minutes after receiving the prescribed IV morphine
Pulses are faintly palpable and the foot is cool. Which action should the nurse take next?
a. Notify the health care provider.
b. Assess the incision for redness.
c. Reposition the left leg on pillows.
d. Check the patient's blood pressure.
ANS: A
The patient's clinical manifestations suggest compartment syndrome and delay in diagnosis and treatment may lead to severe functional impairment. The data do not suggest problems with blood pressure or infection. Elevation of the leg will decrease arterial flow and further reduce perfusion.
You might also like to view...
The nurse places a large-bore nasogastric tube in a patient who has acute upper gastrointestinal bleeding. What is the rationale for this intervention? Select all that apply
A) Aspiration of gastric contents B) Improvement of ventilation C) Decompression D) Enteral feeding E) Lavage of gastric contents F) Control of bleeding
Why is the process of revision of BLS standards from "Airway-Breathing-Circulation" to Circulation-Airway-Breathing considered intervention research? (Select all that apply.)
a. It is grounded in theory. b. It started qualitatively with ideas and observations about the reasons patients code. c. It was field-tested and then researched using randomized clinical trials. d. The findings were replicated in multiple settings. e. It was initiated by a nurse. f. It emanates from previous research on CPR and its outcomes.
A client has been smoking for more than 40 years. He developed a bone tumor in the right hip. What is the greatest risk the client may experience?
A) Fracture B) Pain C) Immobility D) Numbness
A patient tells the nurse, "I'm having a lot of pain in my hip." Which response(s) by the nurse most likely would stimulate the patient to provide the most complete data? Select all that apply
a. "Is your pain severe?" b. "Tell me about your pain." c. "When did you first notice this pain?" d. "How would you describe your pain?" e. "Is your pain better or worse than it was this morning?"