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 ["15"]
Explanation
- To calculate the mL per dose, use the formula: mL = (mg x 5) / 25
- Plug in the given values: mL = (75 x 5) / 25
- Simplify the equation: mL = 15
- Round the answer to the nearest whole number: mL = 15
- The nurse should administer 15 mL of indomethacin per dose.
Correct Answer is B
Explanation
A. Hypovolemic shock is characterized by a significant loss of blood volume. While it can occur due to severe trauma, the symptoms of shortness of breath and chest pain are more indicative of a potential respiratory issue, making Fat Embolism Syndrome (FES) a higher concern in this case.
B. Correct. Given the client's recent multiple long bone fractures and the symptoms of shortness of breath and chest pain, the nurse should be concerned about the possibility of fat embolism syndrome (FES). FES can occur as a result of long bone fractures, particularly those involving the femur, pelvis, or tibia. Fat emboli can enter thebloodstream and potentially obstruct blood vessels, leading to symptoms such as shortness of breath, chest pain, and altered mental status.
C. Venous thromboembolism (VTE) is a condition involving the formation of blood clots in the veins, which can lead to complications such as deep vein thrombosis (DVT) or pulmonary embolism (PE). While this is a consideration for clients with immobilization due to fractures, it is not the primary concern in this case based on the presenting symptoms.
D. Compartment syndrome is a condition characterized by increased pressure within a muscle compartment, leading to decreased blood flow and potential tissue damage. While it can occur after fractures, it typically presents with symptoms like severe pain, swelling, and tense muscles, rather than shortness of breath and chest pain.
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