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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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Correct Answer is A

Explanation

A. Locks the hydraulic valve before attaching the sling to the lift

The hydraulic valve must be unlocked to adjust height and should only be locked after the client is securely attached and raised. Locking it before attaching the sling may indicate improper procedure or reduced safety during lifting.

B. Leaves the bed in the lowest position throughout the procedure

Leaving the bed low can be safe depending on facility protocol and prevents injury if the client or staff lose balance.

C. Raises the head of the bed to a sitting position just before the transfer

Elevating the head of the bed helps the client into a functional sitting position, making sling placement and transfer easier and safer.

D. Places a removable cover over the sling

A removable cover can enhance comfort and hygiene, especially if the sling is shared.

A. Develops fatigue when assisting with morning hygiene care B. Needs assistance raising her legs to put on socks C. Performs active range-of-motion (ROM) exercises of all extremities D. Demonstrates mild dyspnea when eating breakfast

Correct Answer is C

Explanation

A. Develops fatigue when assisting with morning hygiene care

Fatigue during hygiene suggests low endurance; not ready to ambulate safely.

B. Needs assistance raising her legs to put on socks

Needing assistance for simple tasks shows weakness and poor muscle control.

C. Performs active range-of-motion (ROM) exercises of all extremities

Performing full active ROM exercises indicates good muscle strength and coordination, suggesting readiness to attempt ambulation.

D. Demonstrates mild dyspnea when eating breakfast

Dyspnea with minimal activity (eating) indicates limited cardiopulmonary reserve-not yet fit to ambulate.

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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

A nurse is observing an assistive personnel (AP) who is using a mechanical lift with a hammock sling to transfer a client from the bed to a chair. For which of the following actions by the AP should the nurse intervene?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has required strict bed rest for 1 week. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate?

Correct Answer is C

Explanation

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