While performing a neurovascular assessment distal to a client's fracture site, the nurse determines that the client's pulse is present, regular, and full force. Which nursing action should be taken next?

Observe the color of the extremity.

Document the neurovascular assessment as normal.

Discontinue elevating the client's affected extremity.

Notify the healthcare provider of assessment finding.

Answer and Explanation

The Correct Answer is A

A. Observe the color of the extremity: A thorough neurovascular assessment includes evaluating multiple components: pulses, color, temperature, capillary refill, sensation, and motor function. After confirming the pulse, assessing color helps determine perfusion and detect signs of ischemia or compromised circulation distal to the fracture.

B. Document the neurovascular assessment as normal: While the pulse is normal, the neurovascular assessment is incomplete without evaluating other parameters such as color, sensation, movement, and temperature. Documentation should only follow a full and thorough assessment.

C. Discontinue elevating the client's affected extremity: Elevation of a fractured extremity helps reduce swelling and promote venous return. There is no indication that elevation is harmful or unnecessary based on a normal pulse alone. This intervention should continue unless contraindicated.

D. Notify the healthcare provider of assessment finding: A present, regular, and full pulse is a normal finding and does not require immediate provider notification. The nurse should continue the assessment and only notify the provider if abnormal or concerning signs are detected, such as pallor, diminished sensation, or absent pulses.

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Correct Answer is C

Explanation

A. Surgical consent form is not signed: While a signed consent form is legally required before surgery, it can typically be obtained quickly before the procedure. It does not pose an immediate physiological threat, so it can be addressed once life-threatening abnormalities are ruled out.

B. Preoperative chest x-ray report is not available: Although the x-ray may provide important preoperative information, especially in clients with underlying conditions, its absence does not constitute an immediate risk requiring urgent action unless clinical signs suggest a problem.

C. Preoperative serum potassium level is 2.8 mEq/L (2.8 mmol/L): This is a critically low potassium level (hypokalemia), which can lead to life-threatening cardiac arrhythmias during anesthesia. This electrolyte imbalance must be corrected before proceeding with surgery, making it the most urgent concern on the checklist.

D. Client's pulse oximeter reading is 96%: A SpO₂ of 96% is within normal range and does not indicate acute hypoxemia. This value requires no immediate intervention and is acceptable for proceeding with surgery, assuming no other complications are present.

Correct Answer is []

Explanation

Deep vein thrombosis (DVT): The client presents with classic signs of DVT, including calf tenderness, unilateral edema and redness, increased calf circumference, low-grade fever, and a history of immobility following surgery—all of which increase thrombotic risk. A STAT Doppler and D-dimer were appropriately ordered, both of which help confirm or rule out DVT.
Begin anticoagulation therapy: Anticoagulants like enoxaparin reduce clot propagation and the risk of pulmonary embolism, the most serious complication of DVT. This is a standard first-line treatment following a positive diagnosis or high clinical suspicion.
Early ambulation: After stabilization and with provider clearance, early ambulation is encouraged to enhance venous return and prevent further thrombus formation. It must be done cautiously to avoid dislodging a clot if DVT is still untreated or unstable.
Massage the calf area: This is contraindicated, as it may dislodge a clot and cause embolization to the lungs. It is strictly avoided in suspected or confirmed cases of DVT.
Prep for return to surgery / Culture hip wound: These are not relevant to the current clinical concern. The surgical wound has minimal drainage, with no signs of infection or dehiscence.
Development of pulmonary embolus: Clients with DVT are at high risk for PE. Monitoring for chest pain, shortness of breath, decreased oxygen saturation, and respiratory distress is essential for early detection and intervention.
Laboratory values: Ongoing assessment of coagulation labs (PT, aPTT, platelet count) and renal function is critical to safely manage anticoagulation and ensure therapeutic response.
Wound drainage / Nutritional intake / I&O: These are important for general postoperative care but are not specific to monitoring progress related to DVT or anticoagulation therapy.

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While performing a neurovascular assessment distal to a client's fracture site, the nurse determines that the client's pulse is present, regular, and full force. Which nursing action should be taken next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is []

Explanation

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