A nurse is caring for a client postoperative closed reduction of the left ankle with a short cast in place. Which assessments of the client's affected leg should the nurse make? (SELECT ALL THAT APPLY)
Capillary refill
Pain assessment on a scale of 0-10
Ability to move toes
Posterior tibialis and pedal pulses
Skin temperature and color of the toes
Correct Answer : A,B,C,D,E
A. Capillary refill is a key indicator of circulation to the affected area. It should be assessed to ensure adequate perfusion.
B. Pain assessment is critical for identifying any complications such as compartment syndrome or inadequate pain management.
C. The ability to move the toes helps assess for nerve function and mobility.
D. Posterior tibialis and pedal pulses assess the circulation and can help identify signs of vascular compromise.
E. Skin temperature and color help identify signs of poor circulation, swelling, or potential complications like compartment syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Refeeding syndrome occurs when a malnourished patient is given nutrition (such as TPN), leading to electrolyte imbalances (particularly low phosphorus, potassium, and magnesium) that can cause symptoms like muscle cramping, headache, and visual changes. This condition requires immediate correction of electrolyte imbalances and careful monitoring.
B. Sudden hyperglycemia can occur with TPN, but the symptoms described (muscle cramping, headache, and visual changes) are more consistent with refeeding syndrome.
C. An air embolus is a serious complication but is less likely to be the cause of these symptoms.
D. Acute panic attacks could cause some of the symptoms, but the patient's low BMI and history of anorexia nervosa make refeeding syndrome the more likely cause.
Correct Answer is ["A","B","C","D","E"]
Explanation
A. Capillary refill is a key indicator of circulation to the affected area. It should be assessed to ensure adequate perfusion.
B. Pain assessment is critical for identifying any complications such as compartment syndrome or inadequate pain management.
C. The ability to move the toes helps assess for nerve function and mobility.
D. Posterior tibialis and pedal pulses assess the circulation and can help identify signs of vascular compromise.
E. Skin temperature and color help identify signs of poor circulation, swelling, or potential complications like compartment syndrome.
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