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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: This set of values is indicative of metabolic acidosis with respiratory compensation, which is common in chronic kidney disease due to the accumulation of acids in the blood and the lungs' attempt to compensate by retaining CO2.

Choice B reason: This choice suggests respiratory alkalosis, which is less likely in chronic kidney disease unless there is a secondary respiratory condition causing hyperventilation.

Choice C reason: This choice indicates metabolic alkalosis, which is not typical for chronic kidney disease, as the kidneys are unable to excrete acid effectively.

Choice D reason: While this set of values does indicate acidosis, the expected compensatory response in chronic kidney disease would be an elevated PaCO2, not a normal or low value.

A. Offer the client the bedpan every 2 hours. B. Cleanse the perineum from front to back. C. Encourage fluid intake at and between meals. D. Obtain a prescription for an indwelling urinary catheter.

Correct Answer is C

Explanation

Choice A reason: Offering the bedpan every 2 hours is not specifically related to preventing urinary tract infections (UTIs) and may not be necessary unless the client has other needs that require frequent toileting.

Choice B reason: Cleansing the perineum from front to back is a standard practice to prevent the spread of bacteria from the anal area to the urethra, which can reduce the risk of UTIs.

Choice C reason: Encouraging fluid intake is crucial for clients with a spinal cord injury because it helps to flush out the urinary tract, preventing the buildup of bacteria that can cause UTIs.

Choice D reason: An indwelling urinary catheter may be necessary for a client with a T4 spinal cord injury who cannot effectively empty the bladder, but it should be used with caution as it can also increase the risk of UTIs. The decision to use an indwelling catheter should be based on a thorough assessment and consideration of all other options.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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