A nurse at an urgent care center is caring for four clients who all have leg or foot injuries. Which of the following client reports should suggest to the nurse that the client has an ankle sprain?
Was hit by another soccer player on the field
Twisted his foot while running bases during a baseball game
Has ankle pain after running a 16 km (10 mile) race
Dropped a 4.5 kg (10 lb) weight on his lower leg at a health club
The Correct Answer is B
A. Was hit by another soccer player on the field - This suggests a possible collision injury, which may result in various types of leg or foot injuries, but it doesn't specifically point to an ankle sprain.
B. Twisted his foot while running bases during a baseball game - This mechanism of injury is consistent with an ankle sprain. Twisting the foot during a sudden movement can cause stretching or tearing of ligaments around the ankle.
C. Has ankle pain after running a 16 km (10 mile) race - This suggests an overuse or strain injury, which could include various types of leg injuries, but it doesn't specifically point to an ankle sprain.
D. Dropped a 4.5 kg (10 lb) weight on his lower leg at a health club - This suggests a potential crush or impact injury to the lower leg, which may result in various types of leg injuries, but it doesn't specifically point to an ankle sprain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["33"]
Explanation
- To calculate the gtt/min, use the formula: gtt/min = (volume in mL x drop factor) / time in min
- Plug in the values from the question: gtt/min = (100 mL x 10 gtt/mL) / 30 min - Simplify and solve: gtt/min = 1000 gtt / 30 min
- Divide both sides by 30: gtt/min = 33.33 gtt/min
- Round to the nearest whole number: gtt/min = 33 gtt/min
- The nurse should set the manual IV infusion to deliver 33 gtt/min
Correct Answer is B
Explanation
A. Performing range of motion: This should not be done immediately after applying the cast, as it may compromise the integrity of the cast. Range of motion exercises should be initiated once the cast has fully set and as directed by the healthcare provider.
B. Checking capillary refill distal to the cast: This is the priority after applying the cast. It assesses blood flow to the extremity below the cast. Impaired circulation could lead to serious complications, so it's crucial to monitor capillary refill promptly.
C. Teaching the client about cast care: While providing education about cast care is important, it is not the immediate priority. Ensuring proper circulation is more critical in the initial moments after applying the cast.
D. Managing pain: While pain management is important, it is not the immediate priority after applying the cast. Ensuring proper circulation and assessing for any signs of impairment take precedence. Pain management can be addressed once circulation is confirmed to be adequate.
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