Can Anyone Help Me With Some Practice Questions?

[Matt285907]

Here's one question the I found confusing...

A client is in skeletal traction. Which complication should the nurse address first?

A) feeling of doom, increased anxiety, sitting upright

B) nausea, vomiting, gastric reflux

C) elevated temperature, pulse, and blood pressure

D) loss of function of leg, numbness and tingling, edema

Apparently the answer is A. I understand that all of these are important but I would have thought that C would be priority. Can anyone tell me why I'm wrong?? Thanks for your help!

--Matt--

[nicoleRN831]

I would say the reason why A is correct is bc if you address the anxiety then that wont make the bp and pulse and temp go up.

[beth66335, BSN, RN]

Here's one question the I found confusing...

A client is in skeletal traction. Which complication should the nurse address first?

A) feeling of doom, increased anxiety, sitting upright

B) nausea, vomiting, gastric reflux

C) elevated temperature, pulse, and blood pressure

D) loss of function of leg, numbness and tingling, edema

Apparently the answer is A. I understand that all of these are important but I would have thought that C would be priority. Can anyone tell me why I'm wrong?? Thanks for your help!

--Matt--

(A) can be signs of an impending blot clot to the lung (or PE) which can be fatal.

[slacktime]

the feeling of doom & anxiety, and sitting up are signs of impaired gas exchange, maybe clot, pneumothorax, something. This is basic, the "B" of Airway, Breathing, Circulation. If you don't manage "A", the patient could easily lose his life. The other answers are bad signs, but not life threatening.

[lifelines]

Matt,

C is a priority. It deals with the ABCs. These could be signs of infection leading to septic shock

[mygator]

I think correct answer is D, ABC-compartment sindrom

[beth66335, BSN, RN]

Skeletal traction does not cause compartment syndrome and a sense of doom is a classic sign of impending PE

[nikstephdif]

Anytime you see " a feeling of impending doom", that is an indication that the patient can't breathe. Think ABCs!

[kcochrane]

I'm with the impending doom group. Everything else will need to be addressed quickly, but A needs to be addressed ASAP. It can be a PE, shock, etc. That's how NCLEX will look at it. What could kill right NOW.

[NSALVADORE]

Agreed, Impending Doom is a huge warning sign for PE and the patient could be dead within minutes!

Though the others are all important they are not as immediately life threatening as a PE would be, and as another mentioned always go to your ABC's, Breathing :)

[locolorenzo22, BSN, RN]

Lets talk about each one....the question mentions skeletal traction...the biggest complication from immobilzation is clots.

A) feeling of doom, increased anxiety, sitting upright(these are all signs of impaired breathing....if you don't address this, your patient can very quickly go south)

B) nausea, vomiting, gastric reflux(inconvience of course, but these are not as serious...once A is addressed, you can address this)

C) elevated temperature, pulse, and blood pressure (can be anything...from infection to pain to a normal response post meal or just a patients norm)

D) loss of function of leg, numbness and tingling, edema(s/s of a clot to the leg, but the clot to a lung is WAY more important...)

Hope this helps!

[jorjaRN]

yep, this is what's tricky about NCLEX questions...ALL of these answers could be correct, but you need to go with the best answer, and the question is asking which one of these s/sx is the most important to assess first. Always, always go with the ABCs, and a sense of impending doom is a classic giveaway that something needs to be assessed ASAP (in this case his airway is likely compromised, or about to be).

There are a variety of things that can cause elevated HR, BP and temp, which need to be dealt with, but many of which aren't necessarily urgent.