The nurse is collecting data on a patient with a left tibia fracture. Which of the following findings is a priority finding?

Increased red blood cell count

Decreased lymphocyte count

Decreased body temperature

Absent left pedal pulse

Answer and Explanation

The Correct Answer is D

A. Increased red blood cell count: An increased red blood cell count is not an immediate concern in the context of a fracture.

B. Decreased lymphocyte count: A decreased lymphocyte count could indicate an infection or immune issue but is not the immediate priority in a fracture situation.

C. Decreased body temperature: Hypothermia can be concerning, but in the context of a fracture, it is not as critical as neurovascular compromise.

D. Absent left pedal pulse: An absent pedal pulse indicates a possible compromised circulation to the lower extremity, which is a critical and immediate concern. It could signify a compartment syndrome or arterial damage requiring urgent intervention.

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Correct Answer is ["A","B","C"]

Explanation

A. Check the client's toes for color, temperature, and sensation. This assessment ensures that there is no neurovascular compromise, which is crucial for detecting complications like compartment syndrome.

B. Elevate the client's foot. Elevation reduces swelling and helps decrease pain and inflammation.

C. Apply a compression bandage or ace wrap to the client's ankle. Compression helps reduce swelling and provides support to the injured area.

D. Encourage range of motion of the client's foot and ankle. Encouraging range of motion immediately after an acute injury can exacerbate pain and swelling. Immobilization and rest are initially required.

E. Apply heat to the client's ankle. Heat should not be applied in the acute phase as it can increase swelling and inflammation. Cold therapy is recommended initially.

A. Poor circulation B. Uneven cast drying C. Pressure from the cast D. Infection

Correct Answer is D

Explanation

A. Poor circulation: Poor circulation would manifest as coolness, pallor, or decreased pulses distal to the cast, not warmth or odor.

B. Uneven cast drying: Uneven cast drying might cause discomfort or improper immobilization, but it typically does not cause warmth or odor.

C. Pressure from the cast: Pressure from the cast could cause pressure sores, which might lead to infection, but the primary issue here seems to be the signs of infection directly.

D. Infection: Warmth and odor from the cast are indicative of an underlying infection, which is a significant complication requiring prompt attention.

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The nurse is collecting data on a patient with a left tibia fracture. Which of the following findings is a priority finding?

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Naxlex Comprehensive Predictor Exams

A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. Which of the following interventions should the nurse take? (Select all that apply.)

Correct Answer is ["A","B","C"]

Explanation

While collecting data from a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to the touch. The nurse also notices an odor in the area of the cast. Which of the following findings should the nurse identify as a complication to the client's condition?

Correct Answer is D

Explanation

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