A nurse is collecting data from a client who has a long leg cast on his left leg. Which of the following findings is the priority?
Ecchymosis on the inner left thigh
One fingerbreadth of space between the cast and the skin
Diminished pulses on the affected extremity
Client report of muscle spasms of the left leg
The Correct Answer is C
c. Diminished pulses on the affected extremity. This finding may indicate compromised circulation, which is
a serious complication that requires immediate intervention.
Option a. Ecchymosis on the inner left thigh may be a concerning finding, but it is not as urgent as diminished pulses. Ecchymosis may be a result of trauma during cast application, and may resolve on its own.
Option b. One fingerbreadth of space between the cast and the skin is a normal finding and indicates that the cast is not too tight.
Option d. Client report of muscle spasms of the left leg is a common complaint in clients with casts and may
be addressed with medication or other interventions, but it is not as urgent as diminished pulses. Therefore, the priority finding in this scenario is c. Diminished pulses on the affected extremity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
In Hinduism, cremation is the traditional and preferred method of handling the deceased. It is important for the nurse to be culturally sensitive and respectful of the family's religious beliefs and practices while providing postmortem care.
Correct Answer is C
Explanation
A.While increasing dietary fiber can help with constipation, a common side effect of iron supplements, it does not directly improve the absorption of the medication
B.Berries and citrus fruits, on the other hand, are good sources of vitamin C, which can actually enhance iron absorption. Therefore, eliminating them from the diet would not be beneficial for improving iron absorption.
C.The recommendation the nurse should make to improve the absorption of the iron supplement (ferrous sulfate) is to avoid drinking milk with the medication. Calcium in milk can interfere with the absorption of iron, so it is best to separate the consumption of these two substances.
D.Green tea contains compounds called tannins, which can interfere with iron absorption. Therefore, it is not recommended to take iron supplements with green tea.
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