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 C

Explanation

Choice A reason: Keeping the room temperature cool may help with comfort but is not the immediate priority.

Choice B reason: Determining the client's food preferences is important for nutritional management but is not the first action to take.

Choice C reason:

The correct answer is c) because maintaining a patent intravenous site is crucial for administering fluids and medications to address severe dehydration and malnutrition.

Choice D reason: Teaching relaxation techniques can help with restlessness but is not the most immediate concern.

A. The nurse will demonstrate the procedure for accurate eye care. B. The client's blood pressure readings will be less than 160/90 mm Hg. C. The client's hemoglobin A1C will be less than 7% in 3 months. D. The nurse will encourage the client to walk thirty minutes every day.

Correct Answer is C

Explanation

Choice A reason: Demonstrating accurate eye care is important but is not a measurable outcome for managing diabetes.

Choice B reason: Managing blood pressure is important but not the primary goal in the context of newly diagnosed diabetes.

Choice C reason:

The correct answer is c) because achieving a hemoglobin A1C of less than 7% in 3 months is a measurable and relevant outcome for managing type 2 diabetes. It indicates good glycemic control and helps prevent complications.

Choice D reason: Encouraging physical activity is beneficial but is not a specific measurable outcome for diabetes management.

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