Difficulty: Medium
Average Score: 92%
Simulated
Passage / Scenario
Nurses NotesDay 1 1100:
Client admitted from the emergency department after falling at home. Client reports pain in right hip and lower back. Alert and oriented to person, place, and time. Bilateral breath sounds are clear. Pedal pulses +2: skin is pink and warm to touch: movement and sensation intact to extremities. Reddened and ecchymotic areas noted on the middle to lower back and right hip. Slight edema to sacral and iliac region present.
Day 2 0945:
Client unable to void and bladder is distended. Indwelling urinary catheter inserted: draining dark, reddish-brown colored urine: edema to sacral and illac region 2+. Lower extremities cool to touch, pedal pulses 1+ bilaterally, capillary refill time 6 seconds
Diagnostic Results
1200:
CT scan of lower back, hip, and pelvis region shows hairline fractures to right hip and anterior pelvis.
Vital Signs:
Day 1 1200:
Temperature 36.4┬░ C (97.5┬░ F)
Heart rate 92/min
Respiratory rate 22/min
Blood pressure 146/85 mm Hg
Oxygen saturation 95%
Day 2 0945:
Temperature 37.2┬░ C (98.9┬░ F)
Heart rate 108/min
Respiratory rate 24/min
Blood pressure 154/78 mm Hg
Oxygen saturation 96%
The nurse is caring for a client who has a hip and pelvis fracture. Select the 4 findings on Day 2 that require immediate follow-up.
Correct answer
A,C,E,F
Rationale
Heart rate increase, worsening edema, dark reddish-brown urine, and diminished pedal pulses indicate potential complications requiring immediate attention.