A nurse is caring for a client who has musculoskeletal injuries to the left lower extremity. Which of the following assessments should the nurse perform to evaluate the neurovascular status of the client's extremity?
Check skin temperature distal to the injury with the dorsum of the hand.
Press the heel of the foot to determine capillary refill.
Monitor sensation by palpating the pad of the great toe with a blunt needle.
Compare the color of the skin proximal to the injury with the other extremity.
The Correct Answer is A
A. Check skin temperature distal to the injury with the dorsum of the hand.: Assessing skin temperature distal to the injury is an important part of evaluating neurovascular status. It helps to identify any changes in circulation or potential complications like ischemia. The dorsum of the hand is commonly used as it provides a good comparison to the temperature of the affected extremity.
B. Press the heel of the foot to determine capillary refill.: While capillary refill is an important assessment, it is usually measured by pressing the nail beds or pads of the fingers and toes, not by pressing the heel. This method does not provide a reliable indication of neurovascular status.
C. Monitor sensation by palpating the pad of the great toe with a blunt needle.: While assessing sensation is important, it is typically done using a light touch or pinprick, rather than palpating with a blunt needle. The use of a needle is not standard practice for this type of assessment.
D. Compare the color of the skin proximal to the injury with the other extremity.: Comparing the skin color distal to the injury with the unaffected extremity is more relevant for evaluating neurovascular status. Proximal comparison is less effective in assessing circulation and potential issues related to the injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Cleanse the client's finger with an antiseptic swab: The first step in performing a capillary blood glucose test is to cleanse the client’s finger with an antiseptic swab. This reduces the risk of infection and ensures that any contaminants on the skin do not affect the accuracy of the blood glucose reading.
B) Hold the client's finger in a dependent position: Holding the finger in a dependent position can help increase blood flow, but this step is taken after cleansing the finger. The priority is to first clean the area to minimize the risk of infection.
C) Wipe away the first drop of blood: Wiping away the first drop of blood is done to avoid contamination from interstitial fluid and to ensure a more accurate reading. However, this action occurs after the blood sample is obtained, not before the test begins.
D) Place the lancet on the side of the selected finger: While placing the lancet on the side of the finger is important for minimizing discomfort and obtaining an adequate blood sample, it follows the initial steps of cleaning the finger and preparing for the blood draw.
Correct Answer is C
Explanation
A) Use petroleum jelly on a cotton ball to plug your ear when shampooing.
This method can help protect the ear from water exposure during showering or shampooing. However, it doesn't address trauma or hearing impairment prevention as effectively as avoiding pressure changes.
B) Clean dried blood in your ear canal with a cotton-tipped applicator.
Using cotton-tipped applicators can cause trauma to the ear canal and potentially disrupt the surgical site, increasing the risk of complications and impairing hearing.
C) Avoid blowing your nose for 1 month after surgery.
Avoiding nose blowing is crucial because it can create pressure changes in the ear that may disrupt the healing process and cause trauma to the surgical site, leading to potential hearing impairment.
D) Notify your provider if you have popping or crackling sensations in the affected ear.
Popping or crackling sensations can be normal as the ear heals and adjusts post-surgery. While it’s important to monitor symptoms, reporting them is not necessarily about preventing trauma or hearing impairment.
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