A nurse is performing a neurovascular assessment on a client's affected leg after a total hip replacement. Which of the following findings would indicate impairment and require immediate intervention?
Diminished or absent pulses.
Ability to wiggle toes and foot.
Capillary refill of 2 seconds.
Warm temperature compared to the unaffected leg.
The Correct Answer is A
Choice A reason: Diminished or absent pulses suggest compromised arterial blood flow, which may indicate vascular injury or compartment syndrome. This is a critical finding that requires urgent evaluation and intervention to prevent permanent damage.
Choice B reason: The ability to wiggle toes and foot indicates intact motor function and is a reassuring sign of preserved neurovascular status. It does not suggest impairment.
Choice C reason: A capillary refill time of 2 seconds is within normal limits and suggests adequate peripheral perfusion. It does not indicate neurovascular compromise.
Choice D reason: A warm temperature compared to the unaffected leg is not typically concerning. In fact, a cooler temperature would be more indicative of impaired circulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Bronchoscopy is a diagnostic and therapeutic procedure, not a preventive intervention for atelectasis. It is used when obstruction or complications are suspected.
Choice B reason: Frequent turning and ambulation are foundational nursing interventions that promote lung expansion and reduce the risk of atelectasis. They are supported by clinical guidelines.
Choice C reason: Positive pressure ventilation may be used in critical care settings but is not standard for routine postoperative prevention unless the client is ventilated.
Choice D reason: Intermittent oxygen therapy does not directly prevent atelectasis. Oxygen may be used to treat hypoxemia but does not promote alveolar expansion.
Correct Answer is D
Explanation
Choice A reason: A blood glucose of 144 mg/dL is mildly elevated and may warrant monitoring, but it is not an immediate surgical contraindication.
Choice B reason: Smoking increases surgical risks such as poor wound healing and pulmonary complications, but it is a chronic risk factor and not an acute contraindication.
Choice C reason: A hemoglobin of 10.5 g/dL is slightly low and may increase the risk of anemia-related complications, but it is not critical enough to delay surgery.
Choice D reason: An INR of 10 is dangerously elevated and indicates a high risk for bleeding. Surgery should be postponed until the INR is corrected to reduce the risk of hemorrhage.
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