Answered

Read the following case study and answer the questions.

Case Study:

The nurse is caring for a 22-year-old male client admitted with multiple injuries resulting from a motor vehicle accident.

Primary Care Provider Nurse's Notes:

Admitting Notes:
- 1955: Alert and oriented 22-year-old client admitted post motor vehicle accident (rear-ended) after being seen in the ED.
- Diagnosis: Fracture of right femur, right clavicle, and right ribs 5 & 6.
- Seat belt contusion noted across the chest.
- Chest wall symmetrical.
- No lifts, heaves, or thrills.
- No murmurs, gallops, or rubs auscultated.
- S1 and S2 of normal intensity. No S3, S4.
- EKG shows sinus tachycardia at 114/min.
- Pulse oximetry reading 98% on oxygen 2 L/nc.
- Lungs clear bilaterally.
- Radial pulses equal +3/+4 and regular.
- Pedal pulses: Right +2/+4, Left +3/+4.
- Pain of 9 on a 1-10 pain scale to right shoulder, right chest, and right leg relieved with morphine 4 mg IV.
- Vital Signs: T 98.2°F (36.7°C), RR 24 shallow, BP 148/88.
- Skin warm and dry.
- Right arm immobilized in sling.
- Scheduled for open reduction and internal fixation (ORIF) of the right femur.

- 2230: Client stable following ORIF of the right femur. Alert, oriented.
- Vital signs within normal limits/afebrile.
- Lactated Ringers 1 liter infused.
- Postop Hct: 36.
- Fiber cast dry/intact.
- Postop plan: IV hydration, Cefoxitin 1 gram every 8 hours, physical therapy.

Question:
Which of the client's findings would be of immediate concern? Select all that apply.

A. Abdominal assessment
B. Cardiac assessment
C. Cast assessment
D. Respiratory assessment



Answer :

GinnyAnswer
In assessing which of the client's findings would be of immediate concern, we can analyze the provided data from the nurse's notes and the client's vitals:

1. Cardiac assessment: The EKG shows sinus tachycardia with a heart rate of 114 beats per minute. Tachycardia is a condition where the heart rate is higher than normal, and it needs monitoring, as it can be a sign of underlying conditions or stress on the heart, especially in a trauma patient.

2. Respiratory assessment: The respiratory rate is noted to be 24, which is higher than the normal range for adults (12-20 breaths per minute). Additionally, the breathing is described as shallow. Even though the pulse oximetry reading is 98%, the elevated respiratory rate and shallow breathing could indicate respiratory distress or other respiratory issues.

3. Cast assessment: The cast status after the femur surgery is “Fiber cast dry/intact,” and while this is generally a routine follow-up item, it needs regular monitoring to ensure there is no swelling, compromised circulation, or other complications under the cast.

Based on this information, the findings of immediate concern would be:

- Cardiac assessment
- Cast assessment
- Respiratory assessment

Therefore, the client's findings of immediate concern are:
- Cardiac assessment
- Cast assessment
- Respiratory assessment

These areas need continuous monitoring to ensure that any potential complications are detected and managed promptly.

Other Questions