A nurse is assessing the neurovascular status of a client who has had a leg cast recently applied. The nurse cannot palpate the client's dorsalis pedis or posterior tibial pulse, and the client's foot is pale. What is the nurse's most appropriate action?

Promptly inform the primary care provider

Reposition the client with the affected foot-dependent

Warm the client's foot and determine whether circulation improves.

Reassess the client's neurovascular status in 15 minutes

Answer and Explanation

The Correct Answer is A

Rationale:
A. Absent pulses and a pale foot are signs of compromised circulation, which may indicate compartment syndrome or arterial occlusion. This is a medical emergency requiring immediate evaluation and intervention by the primary care provider.
B. Repositioning the foot may not resolve the issue and delays necessary medical attention.
C. Warming the foot is inappropriate when signs of impaired circulation are present; it can mask symptoms and delay emergency care.
D. Delaying reassessment may result in permanent tissue damage if the issue is not addressed promptly. Immediate action is required.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Rationale:
A. Pain radiating to the left shoulder and worsening with deep breathing (Kehr’s sign) is more indicative of splenic injury, not appendicitis.
B. Pain from appendicitis typically worsens with movement and does not improve with eating; improvement with food is more characteristic of peptic ulcer disease.
C. Left lower quadrant pain is more consistent with diverticulitis, not appendicitis.
D. Right lower quadrant pain at McBurney's point with rebound tenderness is a hallmark sign of acute appendicitis, making this the most indicative finding.

A. Check the client's 24-hour fluid balance B. Reducing the rate of the TPN infusion by half C. Perform a finger-stick blood glucose check D. Assessing the client's vital signs

Correct Answer is C

Explanation

Rationale:
A. While reviewing fluid balance is important, it is not the priority in response to symptoms of hyperglycemia.
B. Reducing the TPN rate without verifying the cause of symptoms could lead to undernourishment or abrupt changes in glucose levels.
C. Blurred vision, dry mouth, and frequent urination are classic signs of hyperglycemia. Since TPN contains high levels of glucose, a finger-stick blood glucose check is the priority to confirm and address potential hyperglycemia.
D. Vital signs are important, but do not directly assess the suspected cause of the client's symptoms in this case.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assessing the neurovascular status of a client who has had a leg cast recently applied. The nurse cannot palpate the client's dorsalis pedis or posterior tibial pulse, and the client's foot is pale. What is the nurse's most appropriate action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 20-year-old client presents to the emergency department with abdominal pain. Which assessment finding is most indicative of acute appendicitis?

Correct Answer is D

Explanation

The nurse is caring for a client who was started on total parenteral nutrition (TPN) 2 days previously. The client complains of blurred vision, dry mouth, and frequent urination. Which is the nurse's priority action?

Correct Answer is C

Explanation

A nurse is reviewing the chart of a client who has been taking pantoprazole (Protonix) daily for over a year. Which of the following findings should the nurse recognize as a potential complication of long-term therapy?

The nurse is teaching self-care to a client with a newly applied cast to the forearm. Which of the following does the nurse instruct the client to notify the practitioner immediately?

The nurse reviews the laboratory test results for a client diagnosed with leukemia who is receiving chemotherapy. The nurse notes that the client's platelet count is 20,000 cells/mm3(reference range 150,000 - 450,000). The nurse should prepare to implement a specific action based on this finding.

A nurse is caring for a client scheduled to receive external radiation to the neck for cancer of the larynx. During a pre-treatment exam, the nurse explains to the client that the most likely side effect would be

A client with a hiatal hernia is prescribed omeprazole (Prilosec). Which explanation by the nurse best describes the purpose of this medication?

A client with systemic lupus erythematosus (SLE) is preparing for discharge. The nurse knows that the client has understood health education when the client makes what statement?

A client who underwent a mastectomy 24 hours ago is found to have a hematoma in the surgical site, as evidenced by increased swelling and a firm, bluish discoloration. Which of the following actions should the nurse take first?