A nurse is assessing a client who is in skeletal traction for a fractured left tibia. The nurse should identify that which of the following findings indicates altered tissue perfusion of the affected extremity?
Pain with movement of the left great toe
Faint pedal pulse of left leg
Warm skin temperature distal to pin site
Purulent drainage at the pin site
The Correct Answer is B
Choice A reason:
Pain with movement of the left great toe is incorrect finding: Pain may be expected in a client with a fractured left tibia, especially if the great toe is moved. Pain is more related to the fracture and may not specifically indicate altered tissue perfusion.
Choice B reason:
Faint pedal pulse of the left leg is correct because it indicates that the blood flow to the foot is diminished. The pedal pulse is the pulse felt on the top of the foot, and its faintness could suggest reduced arterial blood flow to the foot.
Choice C reason:
Warm skin temperature distal to the pin site is incorrect: Warm skin distal to the pin site may indicate adequate blood flow and could be a normal finding. Warmth is generally associated with increased blood flow to the area.
Choice D reason:
Purulent drainage at the pin site is incorrect. Purulent drainage at the pin site could indicate an infection, but it is not directly related to altered tissue perfusion. Infection can lead to complications, but it does not necessarily indicate reduced blood flow to the extremity
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
- A. Diarrhea is not an adverse effect of amitriptyline, which is a tricyclic antidepressant (TCA). Diarrhea may be caused by other factors, such as infection, food intolerance, or stress. Therefore, this choice is incorrect.
- B. Frequent urination is not an adverse effect of amitriptyline either. Frequent urination may be a sign of diabetes, urinary tract infection, or other conditions that affect the kidneys or bladder. Therefore, this choice is also incorrect.
- C. Excessive salivation is not an adverse effect of amitriptyline as well. Excessive salivation may be due to increased production of saliva, difficulty swallowing, or mouth irritation. Therefore, this choice is incorrect too.
- D. Blurred vision is an adverse effect of amitriptyline and other TCAs. Amitriptyline can cause anticholinergic effects, such as dry mouth, constipation, urinary retention, and blurred vision. These effects are more pronounced in older adults and can impair their daily functioning and quality of life. Therefore, this choice is correct and the nurse should identify it as an adverse effect of the medication.
Correct Answer is B
Explanation
A. Incorrect. The nurse should check the functioning of oxygen equipment daily, not weekly, to ensure safety and proper delivery of oxygen.
B. Correct. The nurse should instruct the client to wear clothing made with cotton fabrics while oxygen is in use, as synthetic fabrics can generate static electricity and cause sparks that could ignite the oxygen.
C. Incorrect. The nurse should instruct the client to avoid petroleum-based lubricants, such as Vaseline, as they are flammable and could cause burns if exposed to oxygen. The nurse should recommend water-soluble lubricants, such as K-Y jelly, instead.
D. Incorrect. The nurse should instruct the client to store full oxygen tanks upright, not on their side, to prevent them from rolling and damaging the valve or regulator.
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