After falling down the basement steps, a client is brought to the emergency room. X-rays confirms that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?

Increased temperature to lower extremity.

Right foot pale with sluggish capillary refill.

Circumferential edema of right foot.

Complaint of throbbing right leg pain

Answer and Explanation

The Correct Answer is B

A. Increased temperature to the lower extremity:
While increased temperature could indicate inflammation or infection, it is not as immediately concerning as impaired circulation.

B. Right foot pale with sluggish capillary refill.
This finding suggests a potential impairment in blood flow to the right foot, which could be due to complications such as compartment syndrome or impaired circulation. Compartment syndrome is a serious condition that occurs when there is increased pressure within a muscle compartment, leading to reduced blood flow. Pale color and sluggish capillary refill indicate compromised circulation and require prompt intervention to prevent further damage.

C. Circumferential edema of the right foot:
Edema is a common finding after a fracture and cast application. However, in the context of pale color and sluggish capillary refill, it may indicate increased pressure within the compartment, requiring immediate attention.

D. Complaint of throbbing right leg pain:
Pain is a common complaint after a fracture, and throbbing pain may be expected. However, the priority is to address the potential compromise in circulation indicated by the pale color and sluggish capillary refill.

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Correct Answer is ["A","C","D","E"]

Explanation

A. Measure pulse and blood pressure:
This action is crucial to assess the client's cardiovascular status. Weakness and jitteriness can be related to changes in blood pressure or cardiac function. Measuring pulse and blood pressure helps determine the client's hemodynamic stability.

B. Document anxiety on the surgical checklist:
While anxiety is a valid consideration, addressing the physiological aspects of the client's symptoms takes precedence.

C. Assess skin temperature and moisture:
Assessing skin temperature and moisture provides information about the client's perfusion and hydration status. Changes in skin characteristics can be indicative of underlying issues, and in a diabetic patient, it's important to monitor for potential complications affecting skin integrity.

D. Check fingerstick glucose level:
Given the client's recent diagnosis of type 2 diabetes mellitus and the reported symptoms of weakness and jitteriness, checking the fingerstick glucose level is crucial. Fluctuations in blood glucose levels, whether hyperglycemia or hypoglycemia, can contribute to these symptoms. This test provides immediate information about the client's glycemic status.

E. Administer a PRN dose of regular insulin:
If the fingerstick glucose level indicates hyperglycemia and the healthcare provider has prescribed a PRN (as needed) dose of regular insulin for high blood sugar, administering insulin may be necessary to address hyperglycemia promptly. This is in line with diabetes management protocols, and the nurse should follow specific orders and guidelines for insulin administration.

A. Activity level of bowel sounds B. Eating patterns of dietary intake C. Level and amount of physical activity. D. Color and consistency of feces.

Correct Answer is B

Explanation

A. Activity level of bowel sounds:
Bowel sounds are important to assess, but they may not directly influence or be influenced by the abdominal pain associated with chronic pancreatitis.

B. Eating patterns and dietary intake.
Clients with chronic pancreatitis often experience abdominal pain exacerbated by the intake of food, especially fatty meals. Monitoring the client's eating patterns and dietary intake is crucial for identifying triggers that may worsen the abdominal pain. By understanding the relationship between food intake and pain, the nurse can provide guidance on dietary modifications to help manage the symptoms.

C. Level and amount of physical activity:
While physical activity is important for overall health, it may not be the primary factor contributing to or alleviating the abdominal pain in a client with chronic pancreatitis.

D. Color and consistency of feces:
Monitoring the color and consistency of feces is important for assessing pancreatic function, but it may not be the most immediate factor to address in the context of managing abdominal pain. Dietary patterns are more directly related to pain management in this case.

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After falling down the basement steps, a client is brought to the emergency room. X-rays confirms that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?

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Naxlex Comprehensive Predictor Exams

An overweight, young adult client who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. The client reports feeling very weak and jittery. Which actions should the nurse implement? (Select all that apply.)

Correct Answer is ["A","C","D","E"]

Explanation

The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?

Correct Answer is B

Explanation

A female college student comes to the school's health clinic complaining of urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?

A client who underwent cardiac stent placement four days ago arrives to the emergency department reporting a sudden onset of chest pressure and shortness of breath. Which action should the nurse take next?

After falling down the basement steps, a client is brought to the emergency room. X-rays confirms that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?

Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first?

A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and palpitations. Which finding should the nurse recognize as a possible complication?

A client who has a history of hypothyroidism was initially admitted with lethargy and confusion Which additional finding warrants the most immediate action by the nurse?