Four hours following surgical repair of a compound fracture of the right ulna, the nurse is unable to palpate the client’s right radial pulse. Which action should the nurse take first?

Elevate the client’s right hand on one or two pillows.

Measure the client’s blood pressure and apical heart rate.

Complete a neurovascular assessment of the right hand.

Notify the healthcare provider quickly.

Answer and Explanation

The Correct Answer is C

Choice A reason: Elevating the hand reduces edema, potentially improving circulation, but is premature without assessing the absent radial pulse’s cause. Post-fracture, compartment syndrome or arterial injury risks ischemia. Neurovascular assessment identifies severity, guiding targeted interventions to restore perfusion, making elevation secondary to assessment.

Choice B reason: Measuring blood pressure and heart rate provides systemic data but not localized insight into the absent radial pulse, likely from arterial compression post-surgery. Neurovascular assessment evaluates limb perfusion, detecting compartment syndrome or occlusion, critical for urgent intervention to prevent tissue necrosis.

Choice C reason: Completing a neurovascular assessment evaluates pulse, color, warmth, sensation, and movement. Absent radial pulse post-fracture suggests compartment syndrome or arterial injury, risking ischemia. This confirms vascular compromise, guiding interventions like fasciotomy, addressing the pathophysiological threat to limb viability, ensuring timely treatment.

Choice D reason: Notifying the provider follows assessment. Absent radial pulse suggests compartment syndrome, where swelling impairs arterial flow. Neurovascular assessment quantifies severity (e.g., pallor, paresthesia), ensuring accurate reporting for urgent intervention, preventing delays in treating vascular compromise critical to limb preservation.

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Correct Answer is B

Explanation

Choice A reason: Exercise lowers blood glucose in type 2 diabetes by enhancing insulin sensitivity and glucose uptake via GLUT4 transporters in muscles. This statement is incorrect, as physical activity is vital for glycemic control, reducing hyperglycemia and cardiovascular risks. Proper understanding involves recognizing exercise’s role in metabolic management, not denying its impact.

Choice B reason: Following a tailored meal plan and avoiding high-fat diets is correct, as it regulates blood glucose and lipids in type 2 diabetes. Balanced carbohydrates and low saturated fats prevent insulin resistance and atherosclerosis. This reflects understanding of dietary management’s role in glycemic control, reducing complications like neuropathy or cardiovascular disease.

Choice C reason: Soaking feet in hot water is dangerous in diabetes due to neuropathy, which reduces sensation and increases burn risk. Hot water also dries skin, raising infection risk. Proper foot care involves daily inspection and avoiding extreme temperatures, making this statement incorrect and harmful for effective diabetes management.

Choice D reason: Covering wounds with antibiotic ointment without medical evaluation is risky, as diabetes impairs wound healing due to hyperglycemia and immune dysfunction. Proper care involves cleaning, monitoring, and consulting providers to prevent infections. This statement shows incomplete understanding, as it overlooks the need for professional wound management.

A. Complete an assessment of the client's pain. B. Determine if the client has had a shingles vaccination. C. Perform a complete mental status exam. D. Teach the client about phantom pain symptoms.

Correct Answer is A

Explanation

Choice A reason: Persistent pain after Herpes zoster suggests postherpetic neuralgia (PHN), a neuropathic condition from varicella-zoster virus damaging sensory nerves. Assessing pain intensity, location, and characteristics guides treatment with analgesics or anticonvulsants like gabapentin. This step differentiates PHN from other causes, ensuring targeted therapy to alleviate nerve pain and improve quality of life.

Choice B reason: Checking shingles vaccination status is irrelevant for current pain, as the client already had Herpes zoster. Vaccination prevents initial infection but does not treat PHN, which results from nerve damage during active infection. Pain assessment is critical to address neuropathic symptoms caused by viral-induced sensory nerve dysfunction, making this less urgent.

Choice C reason: A mental status exam evaluates cognition but is not indicated for PHN, a physiological condition from nerve damage, not a cognitive issue. Pain is neuropathic, driven by damaged sensory neurons, not psychological factors. Assessing pain directly addresses the client’s complaint, guiding treatment for nerve-related discomfort, making this action inappropriate.

Choice D reason: Teaching about phantom pain is incorrect, as phantom pain occurs post-amputation, not after shingles. PHN involves persistent nerve pain in the affected dermatome due to viral nerve damage. Misdiagnosing this could delay proper management, as pain assessment is needed to confirm PHN and initiate therapies like gabapentin, not phantom pain education.

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Four hours following surgical repair of a compound fracture of the right ulna, the nurse is unable to palpate the client’s right radial pulse. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which statement by the client indicates understanding?

Correct Answer is B

Explanation

Five months following treatment for Herpes zoster (shingles), an older adult client tells the home health nurse of continuing to experience pain where the rash occurred. Which action should the nurse implement?

Correct Answer is A

Explanation

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