A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia.
Which of the following assessment findings requires immediate intervention by the nurse?
The client's capillary refill in the left toe is 6 seconds.
The client reports a pain level of 7 on a scale from 0 to 10 at the operative site.
The client has an oral temperature of 38.3° C (100.9° F).
The client has 100 mL of blood in the closed-suction drain.
The Correct Answer is A
“The client’s capillary refill in the left toe is 6 seconds.” Capillary refill time is the time it takes for blood to return to the capillaries after pressure has been applied to the skin.
A normal capillary refill time is less than 2 seconds.
A capillary refill time of 6 seconds indicates poor blood flow to the left toe and requires immediate intervention by the nurse.
Choice B is not the correct answer because while a pain level of 7 on a scale from 0 to 10 at the operative site is concerning, it does not require immediate intervention by the nurse.
Choice C is not the correct answer because an oral temperature of 38.3° C (100.9° F) is only slightly elevated and does not require immediate intervention by the nurse.
Choice D is not the correct answer because while 100 mL of blood in a closed-suction drain may be concerning, it does not necessarily require immediate intervention by the nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse should ask the client to empty his bladder prior to the procedure.
This is important because a full bladder can obstruct the area where the needle will be inserted and increase the risk of bladder injury during the procedure.
Choice A is incorrect because the client should be positioned sitting upright or lying in bed with the head of the bed elevated during the procedure.
Choice B is incorrect because administering a stool softener is not necessary following an abdominal paracentesis.
Choice C is incorrect because the client should be instructed to exhale and hold their breath during needle insertion to help move the diaphragm upward and away from the area where the needle will be inserted.
Correct Answer is C
Explanation
Furosemide is a loop diuretic that can cause loss of potassium from the body.
A potassium level of.2 mEq/L is considered low (hypokalemia) and can be a contraindication for receiving the medication.
Sodium 136 mEq/L is within the normal range and is not a contraindication for receiving furosemide.
B) Creatinine 0.8 mg/dL is within the normal range and is not a contraindication for receiving furosemide.
D) BUN 18 mg/dL is within the normal range and is not a contraindication for receiving furosemide.
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