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A nurse performing a head to toe neurovascular check on a patient in a long leg cast notes an indication of altered perfusion as evidenced by:

warm feet and hands.

numbness of distal limb.

palpable peripheral pulses.

capillary refill of 3 seconds.

Answer and Explanation

The Correct Answer is B

A. Warm feet and hands.

Warmth suggests good blood flow and is a normal finding.

B. Numbness of distal limb.

Numbness is a sign of neurovascular compromise, possibly from swelling or impaired circulation due to the cast.

C. Palpable peripheral pulses.

Pulses are a positive finding indicating adequate perfusion.

D. Capillary refill of 3 seconds.

Capillary refill less than or equal to 3 seconds is considered normal.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Raise the head of the bed to 30 to 45 degrees.

While head elevation for comfort is acceptable, it is not the primary responsibility for CPM care.

B. Elevate the machine at the foot of the bed on one pillow.

The CPM machine should lie flat along the bed frame. Elevation on a pillow can cause misalignment or malfunction.

C. Set the proper flexion and extension limits.

The nurse must confirm that the machine is set according to the provider's orders for proper range of motion and to prevent injury.

D. Keep the operated knee warm.

While comfort is important, this is not a priority of CPM machine care and doesn't directly relate to its function.

A. using the spreader bar to turn the patient. B. protecting the cast from soiling. C. grasping the cast over the leg to help in turning. D. easing itching under the cast by scratching with a bent coat hanger. E. turning frequently to the prone position.

Correct Answer is ["B","E"]

Explanation

A. Using the spreader bar to turn the patient.

The spreader bar is not designed for lifting or turning; it maintains cast shape and stability.

B. Protecting the cast from soiling.

Soiling the cast can lead to skin irritation and infection, especially in the perineal area.

C. Grasping the cast over the leg to help in turning.

This can cause pressure points or cast damage; turning should be done using proper support techniques.

D. Easing itching under the cast by scratching with a bent coat hanger.

This is unsafe and can cause skin injury or infection under the cast.

E. Turning frequently to the prone position.

Frequent position changes, including prone if tolerated, help prevent pressure sores and promote circulation.

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A nurse performing a head to toe neurovascular check on a patient in a long leg cast notes an indication of altered perfusion as evidenced by:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse placing a patient following knee replacement surgery into a continuous passive motion (CPM) machine has the responsibility to:

Correct Answer is C

Explanation

A patient has a hip spica cast and will be discharged home to family. The nurse would include in the home education plan information relative to: (Select all that apply.)

Correct Answer is ["B","E"]

Explanation

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