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 A
Explanation
A. Lie down when taking the medication: Sublingual nitroglycerin causes vasodilation, which can lower blood pressure and potentially cause dizziness or fainting. The client should lie down or sit in a comfortable position to minimize the risk of falls or injury.
B. Chew the medication thoroughly: Sublingual nitroglycerin should be placed under the tongue and allowed to dissolve completely, not chewed. Chewing may affect the absorption and effectiveness of the medication.
C. Store the medication in the refrigerator: Sublingual nitroglycerin should be stored at room temperature, away from moisture and heat, not in the refrigerator. Cold storage could reduce the medication's effectiveness.
D. Check the expiration date on the medication every 6 months: While it is important to check the expiration date, every 6 months is not sufficient. The client should check the expiration date more frequently (e.g., every 3 months) and replace the medication if expired to ensure it is effective when needed.
Correct Answer is B
Explanation
A. Digoxin: Digoxin is a cardiac glycoside used to treat heart failure and arrhythmias. It does not directly affect platelet aggregation or coagulation, so it does not increase the risk of bleeding.
B. Ibuprofen: Ibuprofen is a NSAID that, like naproxen, inhibits cyclooxygenase (COX) enzymes. This reduces the production of prostaglandins, which are involved in inflammation and platelet aggregation. This increases the risk of bleeding, especially when used in combination with other NSAIDs like naproxen.
C. Captopril: Captopril is an ACE inhibitor used primarily for hypertension and heart failure. While it can increase potassium levels and cause hypotension, it does not directly increase the risk of bleeding. Its primary effects are related to blood pressure and kidney function.
D. Phenytoin: Phenytoin is an anticonvulsant. While it has numerous drug interactions, it does not directly increase bleeding risk. However, it can affect vitamin K metabolism, which may influence clotting factors, but its effect on bleeding is not as significant as that of NSAIDs.
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