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

Answer and Explanation

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.

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Correct Answer is ["A","B","C"]

Explanation

A. Gradually increasing activity helps in recovery and prevents complications like blood clots.

B. Having the client demonstrate the use of assistive devices ensures proper use and safety during ambulation.

C. Using an abductor pillow helps maintain hip alignment and prevents dislocation while turning in bed.

D. Open-toed house shoes are not recommended as they do not provide adequate support or protection.

E. It is important for the client to manage pain appropriately, including taking medication before activities such as walking.

A. Risk for falls B. Knowledge deficient regarding disease process C. Risk for skin breakdown D. Limited mobility

Correct Answer is A

Explanation

A. Severe kyphosis and osteoporosis increase the risk of falls, which can lead to fractures, making fall prevention the highest priority.

B. While important, education is not the immediate priority compared to preventing falls.

C. Skin breakdown is a concern but is not as critical as the immediate risk of injury from falls.

D. Limited mobility is a concern but secondary to the risk of falls.

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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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which interventions should be included in discharge teaching for a client who has had a total hip replacement? (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","C"]

Explanation

The nurse caring for a patient who has severe osteoporosis. On inspection, the patient has severe kyphosis of the upper back. Which nursing problem takes priority for this patient's care?

Correct Answer is A

Explanation

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