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
“Flush the catheter manually with 0.9% sodium chloride.” The client is receiving continuous bladder irrigation following a transurethral resection of the prostate and reports bladder spasms and decreased urinary output.
These symptoms may indicate that the catheter is blocked with blood clots.
Flushing the catheter manually with 0.9% sodium chloride can help to remove any blood clots and restore urinary output.
Choice A is not the correct answer because removing the indwelling urinary catheter would not address the underlying issue of blood clots blocking the catheter.
Choice B is not the correct answer because decreasing traction on the catheter would not address the underlying issue of blood clots blocking the catheter.
Choice C is not the correct answer because while ibuprofen may provide some pain relief, it would not address the underlying issue of blood clots blocking the catheter.
Correct Answer is A
Explanation
Asking the client “What is meant by the saying, ‘Don’t beat around the bush?’” is a way to assess the client’s abstract thinking.
Abstract thinking involves understanding concepts and ideas that are not concrete or tangible, such as interpreting figurative language or proverbs.
Choice B is incorrect because it assesses the client’s memory rather than their abstract thinking.
Choice C is incorrect because it assesses the client’s attention and concentration rather than their abstract thinking.
Choice D is incorrect because it assesses the client’s insight and understanding of their condition rather than their abstract thinking.
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