A nurse is assessing a client who has a left lower arm fracture. Which of the following findings indicates impaired venous return in the client’s affected arm?
Acute pain
Ecchymosis of the surrounding skin
Increasing edema
Diminishing distal pulse
The Correct Answer is C
Choice A reason: Acute pain is expected with a fracture but does not specifically indicate impaired venous return.
Choice B reason: Ecchymosis, or bruising, can occur with a fracture due to bleeding into the tissue but is not a direct indicator of venous return issues.
Choice C reason: Increasing edema is a sign of impaired venous return as it indicates a buildup of fluid in the tissues, which can occur if the veins are not effectively returning blood to the heart.
Choice D reason: A diminishing distal pulse could indicate arterial impairment rather than venous return issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The normal range for serum creatinine is indeed 0.6 to 1.2 mg/dL for males and 0.5 to 1.1 mg/dL for females. Serum creatinine is a waste product from the normal breakdown of muscle tissue. As kidneys become impaired for any reason, the serum creatinine level rises due to poor clearance by the kidneys.
Choice B reason: A GFR below 60 mL/min/1.73 m for three months or more is one of the criteria for the diagnosis of chronic kidney disease. GFR is a measure of how well the kidneys filter blood, and a lower GFR indicates poorer kidney function.
Choice C reason: Blood urea nitrogen (BUN) levels should indeed be between 7 and 20 mg/dL. BUN measures the amount of nitrogen in your blood that comes from the waste product urea. Urea is made when protein is broken down in your body. BUN levels can rise with the level of protein in your diet and your kidney function[^10^].
Choice D reason: An increase in serum potassium can indicate hyperkalemia, which may be a sign of acute kidney injury. Potassium is a critical electrolyte, and its levels are tightly regulated by the kidneys. High levels can lead to dangerous heart rhythms.
Correct Answer is D
Explanation
Choice A reason: A rosebud like stoma orifice is a normal appearance for a new colostomy, indicating that the stoma is healthy and not in distress.
Choice B reason: Red drainage from a stoma can be normal, especially in the early postoperative period, as the stoma may ooze a small amount of blood. However, if the drainage is excessive or persistent, it should be reported.
Choice C reason: A shiny, moist stoma is also a sign of a healthy stoma. The stoma should be moist and have a pink or red color, similar to the inside of the mouth.
Choice D reason: A purplish colored stoma indicates compromised blood flow and is a sign of ischemia. This is a serious complication that requires immediate medical attention to prevent tissue death.
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