Page 2143 - Saunders Comprehensive Review For NCLEX-RN

Health Problem: Adult Health: Musculoskeletal: Skeletal Injury
Priority Concepts: Clinical Judgment; Tissue Integrity
Reference: Ignatavicius, Workman, Rebar (2018), pp. 1040-1041.

740. Answer: 3

Rationale: Signs of infection under a casted area include odor or purulent
drainage from the cast or the presence of “hot spots,” which are areas of the cast that
are warmer than others. The primary health care provider should be notified if any
of these occur. Signs of impaired circulation in the distal limb include coolness and
pallor of the skin, diminished distal pulse, and edema.
Test-Taking Strategy: Focus on the subject, signs of infection. Think about what
you would expect to note with infection—redness, swelling, heat, and purulent
drainage. With this in mind, you can eliminate options 2 and 4 easily. From the
remaining options, remember that “dependent edema” is not necessarily indicative
of infection. Swelling would be continuous. The hot spot on the cast could signify
infection underneath that area.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Musculoskeletal
Health Problem: Adult Health: Musculoskeletal: Skeletal Injury
Priority Concepts: Infection; Tissue Integrity
Reference: Ignatavicius, Workman, Rebar (2018), p. 1039.

741. Answer: 3

Rationale: Most pain associated with fractures can be minimized with rest,
elevation, application of cold, and administration of analgesics. Pain that is not
relieved by these measures should be reported to the primary health care provider
because pain unrelieved by medications and other measures may indicate
neurovascular compromise. Because this is a new closed fracture and cast, infection
would not have had time to set in. Intense pain after casting is normally not
associated with anxiety or the recent occurrence of the injury. Treatment following
the fracture should assist in relieving the pain associated with the injury.
Test-Taking Strategy: Focus on the subject, intense pain, and focus on the data in
the question. Use of the ABCs—airway, breathing, and circulation—will direct you
to the correct option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Musculoskeletal
Health Problem: Adult Health: Musculoskeletal: Skeletal Injury
Priority Concepts: Pain; Tissue Integrity
Reference: Ignatavicius, Workman, Rebar (2018), p. 1039.

742. Answer: 4

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