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 D

Explanation

Choice A reason: Stridor is a high-pitched sound heard with breathing and is not related to the pattern described.

Choice B reason: Kussmaul respirations are deep and labored, typically associated with metabolic acidosis, not the pattern described.

Choice C reason: Apneustic respirations are characterized by prolonged inspiratory phases, which is not the pattern described.

Choice D reason: This is the correct choice. Cheyne Stokes respirations are characterized by a cyclic pattern of increasing and decreasing tidal volumes followed by periods of apnea, fitting the description provided.

A. Pain B. Hemorrhage C. Infection D. Urinary retention

Correct Answer is B

Explanation

Choice A reason: Pain is a common postoperative symptom and should be managed appropriately. However, it is not typically considered a priority over other complications that can have more immediate and severe consequences.

Choice B reason: Hemorrhage is a significant risk after TURP and can be life-threatening. It is considered a priority because active bleeding can lead to shock and requires immediate intervention.

Choice C reason: Infection is a potential complication after any surgery, including TURP. While important to monitor for, it is generally not as immediately life-threatening as hemorrhage.

Choice D reason: Urinary retention can occur after TURP, but it is often anticipated and managed with the placement of a urinary catheter. It is a concern but not the highest priority immediately following surgery.

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