A nurse is collecting data from a client who has a short arm cast for a fractured wrist. Which of the following findings indicates impaired venous return in the affected arm?
Auscultation of lungs revealing wheezing
A bounding distal pulse
Fever
Pain unrelieved by opioid analgesic
The Correct Answer is D
a. Auscultation of lungs revealing wheezing is not related to venous return in the affected arm. Wheezing is
a high-pitched whistling sound made while breathing and is usually a sign of a respiratory problem.
b. A bounding distal pulse indicates strong arterial blood flow, which is not a sign of impaired venous return. Impaired venous return would more likely result in a weak or absent pulse.
c. Fever could indicate infection but is not specific to impaired venous return. It's a systemic sign that may or may not be related to the cast or the fracture.
d. Pain that is unrelieved by opioid analgesics can be a sign of compartment syndrome, which is a serious complication that can result from impaired venous return and increased pressure within the muscle compartments. This requires immediate medical attention to prevent permanent damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
If a nurse is caring for a client who has a spinal cord injury and suspects that the client has autonomic dysreflexia, the first action the nurse should take is to raise the head of the bed. This can help to lower the client's blood pressure and reduce the risk of complications such as stroke.
b. Checking the client for a fecal impaction is an important step in identifying and treating the underlying cause of autonomic dysreflexia, but it is not the first action the nurse should take.
c. Checking the client's bladder for distention is an important step in identifying and treating the underlying cause of autonomic dysreflexia, but it is not the first action the nurse should take.
d. Ensuring that the room temperature is warm is not a priority intervention for a client who has autonomic dysreflexia.
Correct Answer is A
Explanation
The nurse should call emergency medical services if they find a woman who has collapsed with right-sided weakness and slurred speech. These symptoms could indicate a stroke or other serious medical condition that requires immediate medical attention.
Finding a location for the client to sit, driving the client to the nearest emergency room, and obtaining the number of the client's provider are not appropriate initial actions for the nurse to take in this situation. The priority is to get the client immediate medical attention by calling emergency medical services.
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