for the week of 03.23.09
A nurse is caring for a client diagnosed with a distal tibia and mid-femur fracture. The client has had a closed reduction and application of a long leg plaster cast. Thirty-six hours after surgery, the client suddenly becomes confused, short of breath and spikes a temperature of 103 degrees Fahrenheit. What should be the first action by the nurse with a focus to collect data?
1. check the orientation to time, place, and person
2. obtain the pulse oximetry reading
3. check the distal circulation of the casted extremity
4. take the blood pressure lying and sitting in a Fowler's position
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1 comment:
The correct answer is number: 2
LeMone, P., & Burke, K. M. (Eds.).
(2008).Medical-surgical nursing: Critical thinking in client care (4th ed.).
Upper Saddle River, NJ: Pearson Prentice Hall.
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