A nurse is monitoring a client's lower extremity following the placement of a cast earlier in the day. Which of the following findings should the nurse identify as manifestations of compartment syndrome? (Select all that apply.)

Pale-colored toes

Decreased skin turgor

Pain relieved by analgesia

Diminished capillary refill

Sensation of tingling

Answer and Explanation

Correct Answer : A,D,E

A. Pale-colored toes are a sign of compromised circulation, which is a key manifestation of compartment syndrome. Decreased blood flow to the affected limb can cause pallor, which requires immediate intervention to prevent permanent damage.

B. Decreased skin turgor is incorrect. Skin turgor is an indicator of hydration status and is not directly related to compartment syndrome.

C. Pain relieved by analgesia is incorrect. One of the hallmark signs of compartment syndrome is severe pain that is not relieved by analgesia and worsens with passive movement.

D. Diminished capillary refill is correct. Delayed capillary refill (longer than 2 seconds) suggests poor perfusion, which can indicate increased pressure within the compartment.

E. Sensation of tingling is correct. Paresthesia (tingling or numbness) is an early sign of nerve compression due to swelling within the compartment. If untreated, this can progress to permanent nerve and muscle 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 D

Explanation

A. Holding the irrigation solution bottle 5 cm (2 in) above the sterile container is incorrect because the solution should be poured into a sterile container without contaminating the sterile field. The nurse should pour the solution from a height that avoids splashing and contamination.

B. Opening the outer wrapper of the sterile package toward her body is incorrect. The outer wrapper of a sterile package should be opened away from the body to avoid contamination of the sterile field.

C. Placing the irrigation solution bottle cap on the sterile field is incorrect. The cap should not be placed on the sterile field, as it may introduce contaminants.

D. Placing sterile objects at least 2.5 cm (1 in) from the edge of the sterile field is correct. This practice maintains the sterility of the field by preventing contamination from external sources.

A. Obtain a baseline reading of the FHR and contraction pattern. B. Document the procedure in the electronic medical record. C. Pass the sterile hook to the provider. D. Position the client with a rolled towel under her hips E. Check the fluid for color, odor, and consistency

Correct Answer is A,D,C,E,B

Explanation

A. Obtain a baseline reading of the FHR and contraction pattern.
- Establishing a baseline of fetal heart rate (FHR) and contraction pattern is crucial to assess for any immediate changes following the amniotomy.
D. Position the client with a rolled towel under her hips.
- Positioning the client with a rolled towel under her hips helps to relieve pressure on the vena cava, improve uterine blood flow, and optimize fetal positioning.
C. Pass the sterile hook to the provider.
- The sterile hook is used to break the amniotic sac, and the nurse should pass it to the provider during the procedure.
E. Check the fluid for color, odor, and consistency.
- After the amniotomy, the nurse should assess the amniotic fluid for color (should be clear), odor (should be odorless), and consistency to check for any signs of meconium or infection.
B. Document the procedure in the electronic medical record.
- The nurse should document the amniotomy procedure and any findings (e.g., FHR changes, amniotic fluid assessment) in the medical record after the procedure has been completed.

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 monitoring a client's lower extremity following the placement of a cast earlier in the day. Which of the following findings should the nurse identify as manifestations of compartment syndrome? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a sterile field to perform a dressing change of a client's leg wound. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is assisting in the care of a client who is in active labor and is to undergo an amniotomy. Which of the following actions should the nurse take? (Move the steps into the box, placing them in the order of performance. Use all the steps.)

Correct Answer is A,D,C,E,B

Explanation

A nurse is reinforcing teaching about home safety precautions with the parents of a 3-month-old infant. Which of the following instructions should the nurse include in the teaching?

A nurse is assisting with the care of a client who is 37 weeks of gestation and is undergoing a nonstress test. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a parent of a preschooler about immunizations. Which of the following statements by the parent indicates an understanding of the teaching?

A nurse is reinforcing teaching with a group of adolescent male clients about testicular examinations. Which of the following statements by a client indicates an understanding of the teaching?

A nurse is assisting with the planning of an in-service about updates in wound care for nursing staff. Which of the following sources should the nurse identify as providing the best evidence-based information?

A nurse is administering pancrelipase to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment?

A nurse is completing postmortem documentation for a client. Which of the following information should the nurse include in the documentation?

A nurse in a long-term care facility is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA.. Which of the following actions should the nurse take?