The nurse performing a neurovascular check on a limb in traction would report and document which finding(s) as indicative of altered circulation? (Select the 2 correct answers)
Distal limb can be flexed and stretched
Cap refill >5 sec.
Pulse is equal to unaffected limb
Limb is cool to touch
Patient is aware of touch and warm and cold application
Correct Answer : B,D
A. The ability to flex and stretch the distal limb indicates intact motor function, not altered circulation.
B. A capillary refill time greater than 5 seconds suggests poor peripheral perfusion and possible vascular compromise.
C. A pulse equal to the unaffected limb indicates normal circulation.
D. A limb that is cool to touch suggests decreased blood flow and impaired circulation.
E. Patient awareness of touch and temperature indicates intact sensory function, not circulation issues.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A fracture that has not broken through the skin is called a closed or simple fracture, not a greenstick fracture.
B. A greenstick fracture occurs when the bone bends and cracks but does not break completely, commonly seen in children due to their softer bones.
C. A bone broken into two distinct pieces is a complete fracture.
D. Bone shattered into more than two pieces is called a comminuted fracture.
Correct Answer is B
Explanation
A. This statement shows appropriate understanding of combining elevation and iceto help reduce swelling.
B. Keeping ice on the knee for the entire dayis inappropriate and potentially harmful. Ice should be applied for 15 to 20 minutes at a time, every 2 to 3 hoursduring the first 24 to 48 hours to prevent tissue damage and frostbite.
C. This reflects accurate understanding of ice’s purpose in reducing inflammation and swelling.
D. This indicates the patient understands the duration of ice therapyas commonly recommended after an acute injury.
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