The nurse is caring for a patient who just returned from surgical decompression of the carpal tunnel. Which finding requires the nurse's immediate action?
The patient's fingers are pink and cool bilaterally.
The capillary refill time is 8 seconds.
The patient complains of generalized pain 5/10.
The patient's fingers swollen and warm.
The Correct Answer is B
A. Fingers being pink and cool bilaterally may be expected postoperatively due to anesthesia or positioning and does not indicate an immediate complication.
B. A capillary refill time of 8 seconds is significantly prolonged (normal is ≤2 seconds) and may indicate compromised circulation, possibly due to compartment syndrome or vascular compromise. This requires immediate action to preserve limb function.
C. A pain level of 5/10 is moderate and may be expected after surgery. It does not indicate an urgent issue unless unrelieved by medication or out of proportion to the procedure.
D. Swollen and warm fingers may be part of the normal inflammatory process after surgery but are not immediately life- or limb-threatening.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Normal capillary refill time is generally less than 3 seconds, indicating adequate peripheral perfusion.
B. Four seconds is prolonged and may suggest compromised circulation.
C. Six seconds is significantly delayed and indicates poor perfusion requiring immediate attention.
D. Five seconds is also prolonged and suggests impaired circulation.
Correct Answer is B
Explanation
A. Assisting the child to be pulled up in bed is contraindicated because it can disrupt traction alignment.
B. Keeping the child’s feet firmly against the foot of the bed helps maintain proper traction and alignment of the limb.
C. The heel should be elevated off the footboard to prevent pressure ulcers.
D. High Fowler’s position is not recommended as it may increase pressure on the traction and cause discomfort.
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