Following a fractured left tibia, which necessitated placement of long leg cast, a client is using crutches to ambulate. During an orthopedic follow-up visit, a client reports to the nurse having difficulty managing the crutches. Which assessment should the nurse perform?
Measure capillary refill time.
Palpate for dependent edema.
Determine degree of skin elasticity.
Note hand and forearm strength.
The Correct Answer is D
A. Capillary refill time assessment is more relevant for circulatory status and would not directly address the client's difficulty with crutch management.
B. Palpating for dependent edema would not provide information directly related to the client's ability to use crutches.
C. Assessing skin elasticity is not directly related to the client's ability to manage crutches.
D. Strength in the hands and forearms is essential for proper crutch use, as these muscles bear much of the weight while ambulating with crutches.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Pink-tinged hematuria is expected after the procedure, but reporting should be directed at increased bleeding or other signs of complications.
B. While some activity restrictions are necessary, a complete restriction of all physical activities is generally not advised and can lead to other complications like blood clots or decreased mobility.
C. An incentive spirometer is typically used to prevent respiratory complications post-surgery, but it is not specifically related to nephrolithotomy procedures.
D. Monitoring the urinary output is crucial because decreased output can indicate a blockage or other complications related to the nephrostomy tube.
Correct Answer is B
Explanation
A. A blood alcohol level of 0.09% indicates intoxication but is less immediately critical than lithium toxicity.
B. A serum lithium level of 1.6 mEq/L indicates lithium toxicity, which can be life- threatening and requires immediate medical intervention.
C. Significant weight loss is concerning but not as acute an issue as potential lithium toxicity.
D. Lack of sleep is serious but is a symptom that can be managed; it is not as urgent as addressing potential lithium toxicity.
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