A nurse is assessing a client who has a left lower arm fracture. Which of the following findings indicates impaired venous return in the client’s affected arm?

Acute pain

Ecchymosis of the surrounding skin

Increasing edema

Diminishing distal pulse

Answer and Explanation

The Correct Answer is C

Choice A reason: Acute pain is expected with a fracture but does not specifically indicate impaired venous return.

Choice B reason: Ecchymosis, or bruising, can occur with a fracture due to bleeding into the tissue but is not a direct indicator of venous return issues.

Choice C reason: Increasing edema is a sign of impaired venous return as it indicates a buildup of fluid in the tissues, which can occur if the veins are not effectively returning blood to the heart.

Choice D reason: A diminishing distal pulse could indicate arterial impairment rather than venous return issues.

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Correct Answer is B

Explanation

Choice A reason: An oral temperature of 38.2°C (100.76°F) is slightly elevated but can be expected postoperatively as the body responds to surgical stress. It is not necessarily an indication of a complication unless it rises significantly or is accompanied by other symptoms.

Choice B reason: The output of burgundy colored urine can indicate bleeding in the urinary tract, which is a potential complication after TURP. Normal urine color ranges from pale yellow to deep amber, depending on hydration levels. Burgundy colored urine postTURP could suggest the presence of blood, warranting further assessment and intervention.

Choice C reason: Feeling an urge to void despite having an indwelling urinary catheter can be uncomfortable but is not uncommon after TURP due to irritation of the bladder. It is not typically a sign of a complication unless accompanied by other symptoms such as pain or difficulty urinating once the catheter is removed.

Choice D reason: A pulse rate of 58/min is within the normal resting range for adults, which is typically 60100 beats per minute. A lower than average pulse rate postoperatively might be normal for the patient, especially if they are on medications like betablockers, or it could be a sign of a good fitness level.

A. Dehydration B. Burns C. Shivering D. Seizures

Correct Answer is C

Explanation

Choice A reason: Dehydration is a concern with fever, but it is not a direct complication of hypothermia blanket therapy. It is important to ensure adequate hydration, but the primary concern with hypothermia therapy is not dehydration.

Choice B reason: Burns could occur if the hypothermia blanket malfunctions or is used improperly. However, modern devices have safety features to prevent burns, making this a less likely complication.

Choice C reason: Shivering is a natural response to cooling and can occur as the body attempts to generate heat in response to the lowered temperature from the hypothermia blanket. It can be counterproductive to the therapy and may need to be controlled with medications.

Choice D reason: Seizures are not a typical complication of hypothermia blanket therapy. While meningitis can cause seizures due to inflammation of the brain, the hypothermia blanket itself does not induce seizures.

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A nurse is assessing a client who has a left lower arm fracture. Which of the following findings indicates impaired venous return in the client’s affected arm?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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