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.

Notify the healthcare provider of the assessment finding.

Discontinue elevating the client's affected extremity.

Document the neurovascular assessment as normal.

Answer and Explanation

The Correct Answer is A

Choice A reason:

The correct answer is a) because observing the color of the extremity provides additional information about circulation and potential complications such as compartment syndrome.

Choice B reason: Notifying the healthcare provider is necessary if there are abnormal findings.

Choice C reason: Discontinuing elevation is not necessary unless there are signs of compromised circulation.

Choice D reason: Documenting the assessment as normal comes after completing a thorough assessment.

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Correct Answer is D

Explanation

Choice A reason: Bringing foods from home may encourage eating but does not address the underlying issue of visual perception.

Choice B reason: Reassuring about weight loss recovery is not helpful in the immediate context of improving meal intake.

Choice C reason: Encouraging the family to feed the client may help but does not promote independence.

Choice D reason:

The correct answer is d) because teaching visual scanning techniques can help the client compensate for visual perception difficulties and increase food intake.

A. Visualize the abdominal incision. B. Notify the healthcare provider. C. Obtain sterile towels soaked in saline. D. Assure the client that such feelings occur with wound infections.

Correct Answer is A

Explanation

Choice A reason:

The correct answer is a) because visualizing the abdominal incision will help the nurse assess for wound dehiscence or evisceration, which requires immediate intervention.

Choice B reason: Notifying the healthcare provider is necessary but comes after assessing the wound.

Choice C reason: Obtaining sterile towels soaked in saline is important if dehiscence or evisceration is confirmed but is not the first action.

Choice D reason: Reassuring the client is important but does not address the immediate need to assess the wound.

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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 D

Explanation

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Correct Answer is A

Explanation

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