Page 2146 - Saunders Comprehensive Review For NCLEX-RN

(numbness and tingling in the fingers). Other symptoms include pain unrelieved by
opioids, pain that increases with limb elevation, and pallor and coolness to the distal
limb. Cyanosis is a late sign. Pain that is out of proportion to the severity of the
fracture, along with other symptoms associated with the pain, is not an early
manifestation.
Test-Taking Strategy: Note the strategic word, early. Knowing that compartment
syndrome is characterized by insufficient circulation and ischemia caused by
pressure will direct you to the correct option.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Evaluation
Content Area: Adult Health: Musculoskeletal
Health Problem: Adult Health: Musculoskeletal: Skeletal Injury
Priority Concepts: Client Education; Perfusion
Reference: Lewis et al. (2017), p. 1479.

748. Answer: 4

Rationale: Clients with diabetes mellitus are more prone to wound infection,
wound separation, and delayed wound healing because of the disease. Postoperative
hemorrhage and edema of the residual limb are complications in the immediate
postoperative period that apply to any client with an amputation. Slight redness of
the incision is considered normal, as long as the incision is dry and intact.
Test-Taking Strategy: Note the strategic word, most, and focus on the subject,
complications following surgery for the client with diabetes mellitus. Recalling that
diabetes mellitus increases the client’s chances of developing infection and delayed
wound healing 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: Amputation
Priority Concepts: Glucose Regulation; Tissue Integrity
Reference: Lewis et al. (2017), p. 1487.

749. Answer: 3

Rationale: If the client with an amputation has a cast or elastic compression
bandage that slips off, the nurse must wrap the residual limb immediately with
another elastic compression bandage. Otherwise, excessive edema will form rapidly,
which could cause a significant delay in rehabilitation. If the client had a cast that
slipped off, the nurse would have to call the PHCP so that a new one could be
applied. Elevation on 1 pillow is not going to impede the development of edema
greatly once compression is released. Ice would be of limited value in controlling
edema from this cause. If the PHCP were called, the prescription likely would be to
reapply the compression dressing anyway.
Test-Taking Strategy: Note the strategic word, immediate, and focus on the data in

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