A nurse is caring for a client who has a new short-leg cast on his lower leg to treat an ankle fracture. Which of the following findings requires immediate notification of the provider?
Ecchymosis of the distal foot
Dependent edema distal to the cast
Moderate level of pain
Inability to flex the toes of the casted foot
The Correct Answer is D
A. Ecchymosis of the distal foot may be expected after the application of a cast and is not necessarily an immediate concern unless it is severe or rapidly worsening.
B. Dependent edema distal to the cast can occur as a normal response to immobilization. It is not an immediate concern unless it is severe or associated with other concerning symptoms.
C. A moderate level of pain can be expected after the application of a cast. It should be managed appropriately, but it is not an immediate concern unless it is severe or uncontrolled.
D. Inability to flex the toes of the casted foot suggests a potential issue with circulation or nerve function, which requires immediate notification of the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Hematuria: This is the correct answer. Hematuria, which is the presence of blood in the urine, can be a common complication of pelvic fractures. This occurs due to the potential injury to the bladder or other structures within the pelvis. Monitoring for hematuria is crucial in assessing potential internal injuries and ensuring appropriate management.
B. Impaired taste: Impaired taste is not typically associated with pelvic fractures. It is more likely related to conditions involving the sense of taste or other unrelated factors. It is not a common complication of pelvic fractures.
C. Diarrhea: Diarrhea is not a common complication of pelvic fractures. It is more likely to be caused by gastrointestinal issues, infections, dietary factors, or other medical conditions. It is not directly related to pelvic fractures or their complications.
D. Increased thirst: Increased thirst is not a common complication of pelvic fractures. It may be related to various factors such as dehydration, certain medical conditions like diabetes, or side effects of medications. It is not a direct consequence of pelvic fractures or their associated complications.
Correct Answer is B
Explanation
A: Placing the client in protective isolation is not necessary unless the client is immunocompromised or has another indication for isolation beyond the scoliosis repair.
B: A PCA (patient-controlled analgesia) pump allows the client to manage pain effectively by administering their own pain medication within prescribed limits, which is essential after the significant surgical intervention of scoliosis repair.
C: Keeping the head of the bed at a 30° angle is not specifically indicated for postoperative care following scoliosis repair with Harrington rod instrumentation. The position of the bed should be based on the client's comfort and specific postoperative orders.
D: Repositioning the client by log rolling every 4 hours is important to prevent complications such as pressure ulcers and to promote circulation, but it is not the priority intervention. Pain management postoperatively is crucial for client comfort, promoting mobility, and aiding in the recovery process.
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