A nurse is assessing a client who has just had a lower-leg cast application to stabilize an ankle fracture. Which of the following findings in the affected extremity is the nurse's priority?
Mild edema to the toes.
Ecchymosis at the base of the toes
Numbness in the toes
Pain at the fracture site with movement
The Correct Answer is C
A. Mild edema to the toes: Mild swelling is a common and expected finding after a cast application due to trauma and immobility. It should be monitored but is not an immediate concern unless it progresses or is accompanied by other symptoms.
B. Ecchymosis at the base of the toes: Bruising near the injury site is also expected following a fracture and cast application. While it should be documented, it does not typically indicate a complication unless associated with worsening symptoms.
C. Numbness in the toes: Numbness may signal impaired nerve function or compromised circulation due to increased pressure from the cast, raising concern for compartment syndrome. This requires immediate evaluation to prevent permanent damage.
D. Pain at the fracture site with movement: Some pain is normal after a fracture and casting, particularly with movement. However, it becomes more concerning if it is severe, unrelieved by medication, or accompanied by signs of neurovascular compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Wrap the dialysate with a heating pad before instillation: Warming the dialysate to body temperature helps prevent abdominal cramping and promotes comfort during infusion. It should be warmed using a heating pad, not a microwave, to ensure safe, even heating.
B. Use clean technique when performing the procedure: Peritoneal dialysis requires strict aseptic technique to prevent peritonitis, a serious infection. Clean technique is not sufficient for this sterile procedure and increases infection risk.
C. Advance the catheter into the peritoneum to promote drainage: The catheter should never be advanced by the client. It is surgically placed and should remain secure; any manipulation can cause injury or dislodgment.
D. Lie in the same position throughout the procedure: Changing positions may actually help facilitate better drainage. Clients are often encouraged to move or reposition slightly if drainage is sluggish. Remaining in one position is not necessary.
Correct Answer is B
Explanation
A. Dextrose 5% in water: D5W is compatible with ceftriaxone for IV infusion. It is often used as a diluent for many IV antibiotics, including cephalosporins, and does not pose a risk of harmful interaction with this medication.
B. Lactated Ringer's: Ceftriaxone is incompatible with calcium-containing IV solutions like Lactated Ringer’s. The calcium in LR can bind with ceftriaxone and form precipitates, especially in neonates, posing a risk of embolism or organ damage.
C. 0.9% sodium chloride: Normal saline is compatible with ceftriaxone for reconstitution and infusion. It is commonly used as a safe diluent that does not cause chemical interaction with this antibiotic.
D. Sterile water: Sterile water is often used for initial reconstitution of IV medications. While it lacks electrolytes for large-volume infusions, it does not chemically interact with ceftriaxone in small reconstitution volumes.
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