A nurse is collecting data from a client following the application of a leg cast for the treatment of a fracture. Which of the following findings should the nurse expect to find first if the cast is too tight?
Toes cool to touch
Inability to move toes
Pallor of the toes
Edema of the toes
The Correct Answer is A
The correct answer is choice A: Toes cool to touch.
Choice A rationale: When a cast is too tight, it can compromise blood circulation to the extremity. This results in decreased blood flow and reduced oxygenation, causing the toes to feel cool to the touch.
Choice B rationale: Inability to move toes is a significant concern that can also indicate nerve compression due to a tight cast. However, it may not be the first sign of a tight cast, as impaired blood circulation will likely be evident before nerve damage.
Choice C rationale: Pallor of the toes, or a pale appearance, can occur when there is restricted blood flow. However, the coolness of the toes is often noticeable before pallor develops.
Choice D rationale: Edema of the toes, or swelling, can occur due to a tight cast, but it is usually a later sign. Initially, the toes may feel cool to the touch, followed by other symptoms such as pallor, pain, and eventually, swelling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A,B,D,C
Explanation
The correct sequence of steps the nurse should follow when a client begins to experience a tonic-clonic seizure is:
- Remain with the client and call for help.
- Place the client in the lateral position.
- Check the client for injuries.
- Reorient and reassure the client.
The nurse should first remain with the client and call for help to ensure that additional assistance is on the way. Next, the nurse should place the client in the lateral position to help keep their airway open and prevent aspiration. After the seizure has ended, the nurse should check the client for injuries that may have occurred during the seizure. Finally, the nurse should reorient and reassure the client, who may be confused or disoriented after the seizure.
Correct Answer is ["C","D","E"]
Explanation
Keeping a night light on in the client's room and bathroom can help reduce the risk of falls by improving visibility and orientation at night. Placing the bedside table within the client's reach can help reduce the risk of falls by making it easier for the client to access necessary items without having to get up and move around. Locking the wheels on beds and wheelchairs during transfers can help reduce the risk of falls by providing stability and preventing unwanted movement.
Keeping the bed at a comfortable working height is important for the nurse's comfort and safety while providing care, but it does not directly reduce the risk of falls for the client.
Administering a sedative at bedtime may help the client sleep, but it can also increase the risk of falls by causing drowsiness and disorientation.
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