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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Keep insulins stored in the refrigerator: Insulin should be stored in the refrigerator until it is opened. However, once it is open, it can be stored at room temperature for up to 28 days, depending on the manufacturer’s recommendations. It does not require refrigeration for daily use.
B. Inject air into the regular insulin first: When mixing insulins, the nurse should inject air into the NPH insulin (cloudy) first, not the regular insulin (clear). This prevents contamination of the regular insulin vial with the NPH insulin.
C. Aspirate NPH insulin first: After injecting the correct amount of air into the vial, the nurse should draw up the clear insulin (regular) first, followed by the cloudy insulin (NPH) to prevent contamination.
D. Roll the cloudy insulin between the hands several times: NPH insulin is cloudy and needs to be gently rolled between the hands to mix the insulin properly. Shaking the vial can cause air bubbles or break down the insulin.
Correct Answer is B
Explanation
A. Align the transducer to the level of the client's radial artery: The transducer should be aligned to the level of the phlebostatic axis at the fourth intercostal space, mid-axillary line, not the radial artery.
B. Maintain the pressure bag at 300 mm Hg of pressure: The pressure bag should be maintained at 300 mm Hg to ensure that the pressure within the system is higher than the client’s arterial pressure. This helps to prevent blood from flowing back into the tubing.
C. Infuse 0.9% sodium chloride at 150 mL/hr: Infusion through an arterial line is not recommended for fluids like 0.9% sodium chloride, as arterial lines are for pressure monitoring and blood sampling. Fluids should be infused through a separate IV line.
D. Have the client bear down when checking their blood pressure: The client should not bear down when checking blood pressure with an arterial line. Bearing down could artificially raise intra-abdominal pressure and affect the reading.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.