NursGuru
    Med Surg Proctored Exam (Musculoskeletal)- Falcon Institute Of Health And Science
    A nurse is caring for a client who has a hip and pelvis fracture. On Day 1 at 1100, the nurse documents the following: Client admitted from the emergency department after falling at home. Client reports pain 7/10 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 Slight edema to sacral and lilac region present Temp 97.5 F. HR 92. RR 22. BP 146/05. O2 Sat 95% On Day 2 at 0945, the nurse documents the following: Client unable to void and bladder is distended. Indwelling urinary catheter inserted; draining dark, reddish colored urine; Edema to sacral and iliac region 2+. Lower extremities cool to touch, pedal pulses absent bilaterally, capillary refill time >6 seconds. Temp 98.9 F, HR 108, RR 24, BP 154/78, 02 Sat 96% pain reported at 10/10. Based on the day 2 assessment the nurse is concerned that the patient may be developing:

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