Physiological Integrity 1 — Questions and Answers
Question 1: A nurse is assessing a client with acute compartment syndrome in the right lower leg following a tibial fracture. Which finding requires immediate intervention?
- Mild bruising over the fracture site
- Pain that is relieved by elevation of the affected limb
- Pain that is disproportionate to the injury and unrelieved by opioid analgesics (Correct answer)
- A capillary refill time of 2 seconds in the right toes
Correct answer: Pain that is disproportionate to the injury and unrelieved by opioid analgesics
Severe pain disproportionate to the injury that is unresponsive to analgesics is the hallmark early sign of compartment syndrome. This is a surgical emergency requiring fasciotomy to relieve pressure. Pain relief with elevation is not expected — elevation can worsen ischemia in compartment syndrome.
Question 2: A nurse is monitoring a client who received a large volume of 0.9% normal saline during resuscitation. Which acid-base imbalance should the nurse anticipate?
- Metabolic alkalosis
- Respiratory acidosis
- Hyperchloremic metabolic acidosis (Correct answer)
- Respiratory alkalosis
Correct answer: Hyperchloremic metabolic acidosis
Large-volume infusion of normal saline (154 mEq/L of chloride) can cause a dilutional hyperchloremic metabolic acidosis, as excess chloride displaces bicarbonate. This is a well-recognized complication of resuscitation with isotonic saline.
Question 3: A nurse assessing a client with chronic kidney disease (CKD) stage 4 finds the following labs: potassium 6.2 mEq/L, BUN 68 mg/dL, creatinine 4.1 mg/dL. Which finding requires the most urgent intervention?
- BUN of 68 mg/dL
- Creatinine of 4.1 mg/dL
- Potassium of 6.2 mEq/L (Correct answer)
- All values require equal urgency
Correct answer: Potassium of 6.2 mEq/L
Hyperkalemia (K+ 6.2 mEq/L) is the most immediately life-threatening complication because potassium levels above 6.0 mEq/L can cause fatal cardiac dysrhythmias. Elevated BUN and creatinine indicate chronic renal decline but are not acute emergencies.
Question 4: A nurse is caring for a client on mechanical ventilation with the following ABG results: pH 7.30, PaCO2 54 mmHg, HCO3 24 mEq/L, PaO2 78 mmHg. How should the nurse interpret these values?
- Metabolic acidosis, uncompensated
- Respiratory alkalosis, compensated
- Respiratory acidosis, uncompensated (Correct answer)
- Metabolic alkalosis, partially compensated
Correct answer: Respiratory acidosis, uncompensated
pH 7.30 is acidotic. The elevated PaCO2 of 54 mmHg indicates CO2 retention, identifying the cause as respiratory. HCO3 of 24 mEq/L is normal, meaning there is no metabolic compensation yet. This is uncompensated respiratory acidosis, common with hypoventilation on the ventilator.
Question 5: A nurse is performing a physical assessment on a client with cirrhosis of the liver. Which finding is most consistent with this diagnosis?
- Pitting edema of the feet and ankles only
- Ascites, jaundice, and spider angiomata (Correct answer)
- Hypertension and elevated serum albumin
- Bradycardia and peripheral vasoconstriction
Correct answer: Ascites, jaundice, and spider angiomata
Cirrhosis causes portal hypertension (leading to ascites), impaired bilirubin metabolism (jaundice), and abnormal estrogen metabolism (spider angiomata). Serum albumin is typically low due to impaired hepatic synthesis, and clients often have hypotension rather than hypertension.
Question 6: A nurse is caring for a client who is 2 hours post-thyroidectomy. The client suddenly develops carpopedal spasm, tingling around the mouth, and a positive Chvostek's sign. The nurse's priority action is to:
- Administer prescribed oral calcium carbonate and reassess in 30 minutes
- Notify the provider immediately and prepare to administer IV calcium gluconate (Correct answer)
- Place the client in Trendelenburg position to improve cerebral perfusion
- Increase the IV fluid rate to dilute the electrolyte imbalance
Correct answer: Notify the provider immediately and prepare to administer IV calcium gluconate
Post-thyroidectomy hypocalcemia occurs when the parathyroid glands are inadvertently removed or damaged, causing acute hypocalcemia. Carpopedal spasm and positive Chvostek's sign are classic manifestations. IV calcium gluconate is needed for acute treatment — oral calcium is too slow for this emergency.
Physiological Integrity 1
A nurse is assessing a client with acute compartment syndrome in the right lower leg following a tibial fracture.
Which finding requires immediate intervention?