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.

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Correct Answer is C

Explanation

Rationale:
A. Deep breathing and coughing exercises are important but ensuring catheter patency is more critical immediately post-prostatectomy to prevent urinary retention and bladder distention.
B. Strict bed rest is generally not required; early ambulation is encouraged to reduce complications.
C. Maintaining a patent indwelling catheter is essential after prostatectomy to prevent urinary obstruction, bladder distension, and potential damage to the surgical site.
D. Monitoring for infection is important but is a routine ongoing assessment rather than the immediate priority.

A. "I will run my toothbrush in the dishwasher every month" B. "I call my doctor if I notice any excessive menstrual bleeding" C. "I will avoid crowds to keep from infecting others" D. "I will take the antiemetic as soon as the chemotherapy infusion is complete"

Correct Answer is B

Explanation

Rationale:
A. While keeping a toothbrush clean is important, running it in the dishwasher monthly is not an effective or necessary method of infection prevention. A soft-bristled toothbrush should be rinsed and replaced regularly.
B. Excessive menstrual bleeding can indicate thrombocytopenia, a serious side effect of chemotherapy, and should be reported immediately. This statement shows appropriate understanding.
C. Clients with neutropenia should avoid crowds to protect themselves from infection, not to prevent spreading it to others.
D. Antiemetics are most effective when taken before chemotherapy begins, not after the infusion is complete.

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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 client has just undergone a prostatectomy for benign prostatic hyperplasia (BPH). Which of the following nursing interventions is most important in the immediate post-operative period?

Correct Answer is C

Explanation

The nurse is providing teaching to a client who has breast cancer about the adverse effects of chemotherapy. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is B

Explanation

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