what should the nurse monitor for in a patient with compartment syndrome

ATI RN

ATI Capstone Medical Surgical Assessment 2 Quizlet

1. What should be monitored for in a patient with compartment syndrome?

A. Unrelieved pain, pallor, and pulselessness
B. Localized redness and swelling
C. Fever and infection
D. Muscle weakness and fatigue

Correct answer: A

Rationale: Correct Answer: A. Unrelieved pain, pallor, and pulselessness are classic signs of compartment syndrome that indicate inadequate blood flow to the affected area. These symptoms are crucial to monitor as they signify a medical emergency requiring immediate intervention. Choices B, C, and D are incorrect because they do not align with the typical manifestations of compartment syndrome. Localized redness and swelling may be present but are not the primary indicators. Fever and infection are also not specific to compartment syndrome, and muscle weakness and fatigue are not typically prominent symptoms of this condition.

2. A patient with pre-dialysis end-stage kidney disease is asking for dietary recommendations. What should the nurse suggest?

A. Limit protein intake
B. Limit potassium intake
C. Restrict sodium intake
D. Limit phosphorus intake to 700mg/day

Correct answer: D

Rationale: In patients with pre-dialysis end-stage kidney disease, it is crucial to limit phosphorus intake to 700mg/day to manage their condition. High phosphorus levels can lead to complications such as bone and heart problems. Limiting protein intake is essential in later stages of kidney disease, particularly in dialysis patients to reduce the buildup of waste products. While limiting potassium and restricting sodium intake are also important in kidney disease management, the priority for a patient with pre-dialysis end-stage kidney disease is to control phosphorus levels.

3. What are the signs of compartment syndrome?

A. Unrelieved pain, pallor, pulselessness
B. Muscle weakness, hyporeflexia
C. Pins-and-needles sensation, swelling
D. Severe swelling and tightness in the affected extremity

Correct answer: A

Rationale: The correct signs of compartment syndrome include unrelieved pain, pallor, and pulselessness due to increased pressure within a muscle compartment. Choice B, muscle weakness, and hyporeflexia are not typical signs of compartment syndrome. Choice C, pins-and-needles sensation and swelling, are not specific signs of compartment syndrome. Choice D, severe swelling and tightness in the affected extremity, could be seen in compartment syndrome but are not the primary signs.

4. A patient who experienced an acute episode of gastritis should avoid which type of foods?

A. Avoid foods high in potassium
B. Avoid foods high in sodium
C. Increase exercise
D. Drink milk as a snack

Correct answer: A

Rationale: Patients who have experienced an acute episode of gastritis should avoid foods high in potassium. Potassium-rich foods can irritate the gastric lining, exacerbating gastritis symptoms. Therefore, choices B, C, and D are incorrect. Avoiding foods high in sodium is beneficial for other health conditions like hypertension, increasing exercise is generally good for overall health but not specifically for gastritis management, and drinking milk may provide temporary relief for some but is not a definitive recommendation for gastritis management.

5. What is the initial action for treating chest pain in acute coronary syndrome?

A. Administer sublingual nitroglycerin
B. Administer aspirin
C. Check cardiac enzymes
D. Obtain IV access

Correct answer: A

Rationale: The correct initial action for treating chest pain in acute coronary syndrome is to administer sublingual nitroglycerin. Nitroglycerin helps dilate blood vessels, reducing the workload on the heart and improving blood flow to the heart muscle. Administering aspirin can also be beneficial, but the priority is to address chest pain promptly. Checking cardiac enzymes and obtaining IV access are important steps but are not the initial actions needed to alleviate chest pain in acute coronary syndrome.