A nurse is caring for a child who had an open reduction and internal fixation (ORIF) of a femur fracture 12 hours ago. The nurse finds the child pale and short of breath. What action by the nurse takes priority?
A.
Assess oxygen saturation while a coworker calls the physician.
B.
Assess and treat the child for pain or anxiety as needed.
C.
Raise the head of the bed to a 45 °angle and reassess.
D.
Review the child's postoperative hemoglobin and hematocrit.
ANS: A
This child appears to be experiencing a complication of fracture, which may include shock, fat embolism, deep vein thrombosis, pulmonary embolism, and infection. Shortness of breath should alert the nurse to a respiratory complication as a first priority. The nurse should have a coworker call the physician while obtaining other assessment data, including oxygen saturation, vital signs, and a respiratory assessment. Although it is possible that a postoperative hemoglobin and hematocrit are low enough that the child is experiencing shock, the priority steps in assessing and intervening are airway, breathing, and circulation (ABCs), so breathing comes before circulation. The child may have pain or anxiety, but these are not the priority. Raising the head of the bed may or may not be helpful, but the nurse first needs to assess oxygen saturation.
You might also like to view...
The daughter of a patient who is dying questions the placement of her father on the medical- surgical care unit (MSCU). She requests he be placed in the intensive care unit (ICU) because of concern her father may not receive close observation on a busy hospital unit. Which action is indicated by the nurse?
1. Notify the intensive care unit of an impending transfer. 2. Tell the daughter that her father does not meet criteria for placement in the more expensive ICU. 3. Discuss the care that can be provided on the unit with the family member. 4. Contact the physician.
A 20-year old female has come to the clinic for a yearly female exam. This is her first and she is very anxious, fearful, and embarrassed. She has never had one before and unsure of what to expect
a. List some ways the nurse can make the client less anxious and fearful going into an examination. b. What is the difference between subjective and objective data?
A client with chronic sinusitis complains of heart palpitations and nervousness following the use of Afrin (pseudoephedrine) nasal spray. The nurse recognizes that these side effects are the result of which classification of medication?
1. Sympathomimetics 2. Adrenergic blockers 3. Histamines 4. Parasympathomimetics
Electronic blood pressure devices require the use of a stethoscope.
Answer the following statement true (T) or false (F)