Fundamentals of Nursing Q 290
Ryan underwent an open reduction and internal fixation of the left hip. One day after the operation, the client is complaining of pain. Which data would cause the nurse to refrain from administering the pain medication and to notify the health care provider instead?
A. Left hip dressing dry and intact.
B. Blood pressure of 114/78 mm Hg; pulse rate of 82 beats per minute.
C. Left leg in functional anatomic position.
D. Left foot cold to touch; no palpable pedal pulse.
Correct Answer: D. Left foot cold to touch; no palpable pedal pulse.
A left foot cold to touch without palpable pedal pulse represents an abnormal finding on neurovascular assessment of the left leg. The client is most likely experiencing some complication from surgery, which requires immediate medical intervention. The nurse should notify the health care provider of these findings.
Option A: A dry and intact hip dressing is a normal assessment of findings that do not require medical intervention. A dressing is considered INTACT if portions of the white dressing border have lifted from the skin as long as the clear viewing window maintains full contact with the skin. The skin under the viewing window does not appear visibly soiled with exudate or blood. The skin under the viewing window does not appear dampened or moist with sweat, exudate, fluid, or blood.
Option B: A blood pressure of 114/78 mm Hg and pulse rate of 82 beats per minute are normal assessment findings that do not require medical intervention. The normal range used in an adult is between 60 to 100 beats /minute with rates above 100 beats/minute and rates and below 60 beats per minute, referred to as tachycardia and bradycardia, respectively. The respiratory rate is the number of breaths per minute. The normal breathing rate is about 12 to 20 beats per minute in an average adult.
Option C: A left foot in functional anatomic position are all normal assessment findings that do not require medical intervention. It functions as a rigid structure for weight-bearing and it can also function as a flexible structure to conform to uneven terrain.