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 A
Explanation
Choice A reason: Right lower quadrant.
McBurney's point is located in the right lower quadrant of the abdomen, which is one-third of the distance from the anterior superior iliac spine to the umbilicus. This is the area where tenderness is most likely to be maximal in cases of acute appendicitis.
Choice B reason: Left lower quadrant
The left lower quadrant is not typically associated with appendicitis pain, as the appendix is located in the right lower quadrant of the abdomen.
Choice C reason: Right upper quadrant
The right upper quadrant is generally associated with other conditions such as gallbladder issues, not appendicitis.
Choice D reason: The left upper quadrant
The left upper quadrant is also not associated with appendicitis pain, as it is on the opposite side of the typical location of the appendix.
Correct Answer is D
Explanation
Choice A reason: This choice is incorrect. Partial compensation would typically involve a change in PaCO2 to counterbalance the elevated bicarbonate, which is not observed here.
Choice B reason: This choice is incorrect. Respiratory acidosis is characterized by a low pH and an elevated PaCO2, which is not consistent with the given values.
Choice C reason: This choice is incorrect. Respiratory alkalosis would present with a low PaCO2 due to hyperventilation, which is not the case here.
Choice D reason: This is the correct choice. The elevated pH and HCO3 with a normal PaCO2 indicate metabolic alkalosis without respiratory compensation. Persistent vomiting can lead to loss of stomach acid, which causes metabolic alkalosis.
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