A nurse is evaluating a client who has impaired mobility after receiving casting on their legs bilaterally. Which of the following findings requires Intervention by the nurse?

Oral temperature 37.8° C (100 F)

Client can wiggle their toes

Feet warm to the touch

Pedal pulses +1

Answer and Explanation

The Correct Answer is D

A. Oral temperature 37.8° C (100.0° F): A mild fever (37.8° C) could be a normal response to trauma or stress, especially following casting. It does not necessarily indicate an urgent issue, but it should be monitored, particularly if it increases or persists.
B. Client can wiggle their toes: The ability to move the toes is a positive sign that the neurovascular function of the extremities is intact. This is reassuring and indicates that circulation and nerve function are being maintained.
C. Feet warm to the touch: Warm feet suggest that there is adequate blood circulation to the extremities. This is a positive finding and does not require intervention unless other signs of complications arise.
D. Pedal pulses +1: A +1 pulse indicates weak pulses, which is concerning after casting. It may be a sign of reduced circulation, and the nurse should assess for further complications such as compartment syndrome, which can result in inadequate blood flow and tissue damage.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Administer digoxin by IV bolus: Digoxin is contraindicated in heart block, as it can worsen the condition. In third-degree heart block, it could further disrupt the electrical signals between the atria and ventricles.

B. Prepare the client for temporary pacing: Third-degree heart block leads to a slow and ineffective heart rate. Temporary pacing is needed to restore the heart’s normal rhythm and improve cardiac output.

C. Instruct the client to perform the Valsalva maneuver: The Valsalva maneuver is used for certain arrhythmias, but not for third-degree heart block. It could slow the heart rate further and worsen the block.

D. Perform carotid sinus massage: Carotid sinus massage is used for arrhythmias like atrial fibrillation or supraventricular tachycardia. In heart block, it could decrease the heart rate even more, making the condition worse.

A. Metabolic alkalosis B. Metabolic acidosis C. Respiratory acidosis D. Respiratory alkalosis

Correct Answer is B

Explanation

A. Metabolic alkalosis: In metabolic alkalosis, the pH is elevated (above 7.45), and the bicarbonate (HCO3) is increased (above 28 mEq/L). In this scenario, the pH is low (7.12), and HCO3 is low (20 mEq/L), which is not consistent with alkalosis.

B. Metabolic acidosis: In metabolic acidosis, the pH is low (below 7.35), and the bicarbonate (HCO3) is low (below 21 mEq/L), which is consistent with the client's ABG values (pH 7.12, HCO3 20 mEq/L). This suggests the client has metabolic acidosis, which is common in chronic kidney failure due to impaired excretion of acid and decreased bicarbonate.

C. Respiratory acidosis: In respiratory acidosis, the pH is low, and the PaCO2 is elevated (above 45 mm Hg). The PaCO2 in this client is within the normal range (40 mm Hg), making respiratory acidosis unlikely.

D. Respiratory alkalosis: In respiratory alkalosis, the pH would be high, and the PaCO2 would be low (below 35 mm Hg). The client's pH is low (7.12), and the PaCO2 is normal, so respiratory alkalosis is not present.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is evaluating a client who has impaired mobility after receiving casting on their legs bilaterally. Which of the following findings requires Intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who is scheduled for a kidney transplantation. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is caring for a client who has chronic kidney failure. The client's ABG values are pH 7.12 (7.35 to 7.45), HCO3 20 mEq/L (21 to 28 mEq/L), PaO2 90 mm Hg (80 to 100 mm Hg), and PaCO2 40 mm Hg (35 to 45 mm Hg). Which of the following acid-base Imbalances should the nurse identify?

Correct Answer is B

Explanation

A nurse in a health clinic is caring for a client. Exhibits Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing dropdowndue todropdown.

A nurse is teaching a client who has type 1 diabetes mellitus about treating a hypoglycemic episode. Which of the following statements should the nurse include in the teaching?

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following nursing actions are appropriate? (Select all that apply.)

A nurse is reviewing provider prescriptions for a client who has reduced kidney function. Which of the following prescribed diagnostics should the nurse question?

A nurse is planning care for a client who is experiencing seizures secondary to meningitis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

A nurse is teaching a client who has HIV about infection prevention. The nurse should instruct the client to avoid contact with which of the following items?

A nurse is assessing a client who has syndrome of inappropriate antidiuretic hormone. Which of the following findings should the nurse expect?

A nurse is caring for a client who experienced a stroke and has dysphagia. Which of the following referrals should the nurse anticipate the provider to prescribe?