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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: The prone position is not suitable for abdominal paracentesis as it does not allow access to the abdominal cavity.
Choice B reason: The lateral position is also not suitable as it can cause the fluid to shift, making it difficult to remove.
Choice C reason: While the supine position is commonly used for many medical procedures, it is not the best choice for abdominal paracentesis due to the distribution of fluid.
Choice D reason: The upright position is preferred because it allows the fluid to pool at the lowest point of the abdominal cavity, facilitating its removal.
Correct Answer is C
Explanation
Choice A: Sleepy, but arousing when the name is called
Feeling sleepy after receiving morphine is a common side effect. However, the fact that the client can be aroused when their name is called suggests that this is not necessarily an adverse effect.
The nurse should continue monitoring the client but may not consider this as a significant adverse reaction.
Choice B: Pain level of 6 on a scale from 0 to 10
Pain relief is one of the intended effects of morphine. Therefore, experiencing pain reduction is not an adverse effect.
The nurse would likely view this as a positive response to the medication.
Choice C: Respiratory rate of 8/min
A respiratory rate of 8 breaths per minute is significantly low and indicates respiratory depression, which is a serious adverse effect of morphine.
The nurse should be concerned about this finding and take appropriate action.
Choice D: SaO2 94%
An oxygen saturation (SaO2) level of 94% is within the normal range (usually 95% or higher). It is unlikely to be directly related to morphine administration.
While this value is not concerning, the nurse should continue monitoring the client's oxygen saturation.
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