A nurse is assessing a client following the application of a leg cast for the treatment of a fracture. If the cast is too tight, which of the following findings should the nurse expect to observe first?
Inability to move toes.
Pallor of the toes.
Change in temperature of the toes.
Edema of the toes.
The Correct Answer is B
A. Inability to move toes may be a sign of tightness in the cast, but it is not the first finding to be expected if the cast is too tight.
B. Pallor of the toes indicates compromised blood flow and is the earliest sign of circulatory impairment due to tightness of the cast.
C. Change in temperature of the toes may be a sign of impaired circulation, but it is not the earliest finding to be expected.
D. Edema of the toes may occur as a result of compromised circulation, but it is not the first finding to be expected if the cast is too tight.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Palpating the femoral pulse is an essential part of assessing the neurovascular status of a client with a femur fracture. The presence and strength of the femoral pulse can indicate adequate blood flow to the lower extremity.
B. While measuring the circumference of the thigh can provide some information about swelling or changes in the size of the limb, it does not directly assess neurovascular status.
C. Monitoring the client's calf for edema is important for assessing for signs of deep vein thrombosis (DVT) or venous insufficiency, but it is not the primary technique for assessing neurovascular status.
D. Instructing the client to wiggle his toes is a way to assess motor function and nerve function, which is part of the neurovascular assessment. However, it is not the initial step in assessing neurovascular status in a client with an unrepaired femur fracture. The femoral pulse should be assessed first to ensure adequate blood flow.
Correct Answer is C
Explanation
A. Fasting is not necessary for a dual-energy x-ray absorptiometry (DXA) scan, as it does not involve ingesting anything.
B. The client does not need to lie flat for an extended period following a DXA scan. They can resume normal activities immediately after the test.
C.The nurse should instruct the client to remove all jewelry or metal objects that can interfere with the test. A DXA scan is the mostly commonly used screening and diagnostic tool for measuring bone mineral density.
D. . It is not necessary to empty the bladder before the test.
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