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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Assess the client for hypoglycemia: The client is receiving dextrose-containing fluids, which help maintain blood glucose levels. Hypoglycemia is not likely the cause of decreased urine output in this context and is not the priority assessment.
B. Administer a bolus of the IV fluid: Providing a fluid bolus without first assessing fluid status may lead to fluid overload, especially if the client is already retaining fluids. This action should only follow appropriate clinical assessment.
C. Assess the client's lung sounds: Decreased urine output may signal fluid retention or early fluid overload. Assessing lung sounds is critical to detect crackles or other signs of pulmonary congestion, which can indicate complications from IV fluid administration.
D. Administer furosemide 10 mg PO: Administering a diuretic without evaluating the client's fluid balance and lung sounds can be unsafe. This decision requires a provider's orderand should follow a thorough assessment of the client’s volume status.
Correct Answer is C
Explanation
A. Varicella:Varicella (chickenpox) requires airborne and contact precautions due to its high transmissibility via respiratory droplets and contact with skin lesions. While contact precautions are used, the primary precaution is airborne.
B. Pertussis:Pertussis is transmitted through respiratory droplets, so droplet precautions are the appropriate measure. Contact precautions are not necessary unless there are heavy respiratory secretions contaminating surfaces.
C. Clostridium difficile:Contact precautions are essential for clients with C. difficile due to the spore-forming nature of the bacteria, which can survive on surfaces. Gown and gloves are required when entering the room, and hand hygiene with soap and water is necessary after contact.
D. Mycobacterium tuberculosis:TB is transmitted via airborne particles, requiring airborne precautions and a negative pressure room. Contact precautions are not indicated for TB unless there are additional infections with contact-spread pathogens.
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