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    Ati pn adult medical surgical 2023 proctored exam
    Select All That Apply

    A nurse is assisting in the care of a client who is in the emergency department (ED) following a ski accident. The nurse is collecting data on the client. Which of the following findings require follow up? Select all that apply.

    Explanation & Rationale

    A. Temperature: The client’s temperature is within normal limits at 36° C (96.8° F) and does not indicate infection or systemic complications at this time. No immediate follow-up is required for temperature. B. Findings of right lower extremity assessment: Swelling, ecchymosis, visible bone, and displacement indicate a severe open fracture. These findings require urgent follow-up to prevent further tissue injury, infection, and neurovascular compromise. C. X-ray results: The X-ray confirms an open spiral tibial shaft fracture, which is a serious orthopedic injury requiring surgical intervention. Prompt reporting and coordination with orthopedic surgery are necessary for definitive management. D. Pain level: The client reports severe pain (10/10), which may indicate ongoing tissue damage or inadequate analgesia. Pain management and continuous monitoring are essential to prevent complications and improve comfort. E. Level of consciousness: The client is alert and oriented to person, place, and time. No follow-up is required regarding mental status at this time. F. Right pedal pulses: The weak right pedal pulse, cool foot, minimal movement, and reduced sensation indicate compromised perfusion and potential neurovascular injury. Immediate follow-up is required to prevent ischemic complications. G. Oxygen saturation: Oxygen saturation is within normal limits at 97% on room air, indicating adequate oxygenation. No immediate follow-up is required.

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