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.

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Correct Answer is D

Explanation

A. Albumin 4.8 g/dL (3.5 g/dL to 5 g/dL): This albumin level is within the normal range and does not suggest a complication of cirrhosis. Cirrhosis often leads to low albumin levels, so a level of 4.8 g/dL is a positive finding and not indicative of a complication.

B. WBC count 8,000/mm3 (5,000 to 10,000/mm3): This white blood cell count is within the normal range and does not suggest a complication. An elevated WBC count may occur in cirrhosis if there is an infection, but this value is within the normal range.

C. Platelets 325,000/mm3 (150,000 to 400,000/mm3): This platelet count is also within the normal range. Cirrhosis typically causes a decrease in platelet count due to spleen enlargement (splenomegaly) or bone marrow suppression.

D. RBC count 4 million/mm3 (4.2 to 5.4 million/mm3): This red blood cell count is lower than the normal range, which could indicate anemia, a common complication of cirrhosis. Anemia in cirrhosis can result from various factors, including chronic bleeding (such as from varices), poor nutrition, or bone marrow suppression.

A. "I don't have to worry about a rejection for at least 6 months after the transplant. B. "My weight should be monitored daily after the transplant C. "I shouldn't expect urine production for the first 12 hours." D. "I should expect a low-grade fever for the first few days after the transplant."

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.

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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?

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