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Author Question: A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment ... (Read 109 times)

APUS57

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A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern?
 
  a. The catheter has been in place for 20 hours.
  b. The client has poor vascular access in the upper extremities.
  c. The catheter is placed in the proximal tibia. d.
  The client's left lower extremity is cool to the touch.

Question 2

A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?
 
  a. Redness at the catheter insertion site
  b. Report of headache and stiff neck
  c. Temperature of 100.1  F (37.8  C)
  d. Pain rating of 8 on a scale of 0 to 10



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parshano

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Answer to Question 1

ANS: D
Compartment syndrome is a condition in which increased tissue perfusion in a confined anatomic space causes decreased blood flow to the area. A cool extremity can signal the possibility of this syndrome. All other findings are important; however, the possible development of compartment syndrome requires immediate intervention because the client could require amputation of the limb if the nurse does not correctly assess this perfusion problem.

Answer to Question 2

ANS: B
Complications of epidural therapy include infection, bleeding, leakage of cerebrospinal fluid, occlusion of the catheter lumen, and catheter migration. Headache, neck stiffness, and a temperature higher than 101  F are signs of meningitis and should be reported to the provider immediately. The other findings are important but do not require immediate intervention.





 

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