A nurse is assessing a client who is 4 hr. postoperative following arterial revascularization of the left femoral artery. Which of the following findings should the nurse report to the provider immediately?

Pallor in the affected extremity

Urine output 150 ml over 4 hr

Temperature of 37.9° C (100.2°F)

Bruising around the incisional site

Answer and Explanation

The Correct Answer is A

A) Pallor in the affected extremity:
Pallor in the affected extremity is a critical finding that indicates potential compromised blood flow to the area, which can be a sign of graft failure, arterial occlusion, or inadequate perfusion. This requires immediate evaluation by the healthcare provider to prevent serious complications such as limb ischemia or loss.

B) Urine output 150 ml over 4 hr:
While low urine output can be concerning, a urine output of 150 ml over 4 hours may not be immediately alarming unless there are other symptoms of acute kidney injury or dehydration. This would need to be monitored, but it is less urgent compared to signs of compromised blood flow.

C) Temperature of 37.9° C (100.2°F):
A temperature of 37.9°C (100.2°F) is mildly elevated and may indicate a low-grade fever, which can occur postoperatively due to various reasons, including inflammatory responses. It is not as immediately critical as signs of impaired perfusion.

D) Bruising around the incisional site:
Bruising around the incisional site is a common postoperative finding and typically not immediately concerning unless it is associated with significant bleeding or signs of hematoma formation. It should be monitored but does not generally require immediate reporting unless accompanied by other alarming symptoms.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Remove one of the weights:
Removing a weight from skeletal traction can compromise the effectiveness of the traction, potentially leading to improper alignment and healing of the fracture. The weights are essential for maintaining the proper alignment and stability of the fractured bone, so altering them without proper medical guidance is not advisable.

B. Tie knots in the ropes near the pulleys to shorten them:
Tying knots in the ropes to shorten them is not a safe or appropriate method for adjusting traction. It can lead to uneven force distribution, poor alignment, and potential injury. Traction adjustments should be made by qualified personnel using proper equipment and methods.

C. Pull the client up in bed:
Pulling the client up in bed helps to ensure that the weights are properly suspended and not resting on the floor. This action helps maintain the effectiveness of the skeletal traction by ensuring that the appropriate amount of force is applied to the fracture. It also prevents potential complications associated with improperly positioned weights.

D. Increase the elevation of the affected extremity:
Increasing the elevation of the affected extremity might be indicated to reduce swelling or improve comfort but does not address the issue of weights resting on the floor. Proper positioning of the weights is crucial for effective traction and must be corrected to ensure optimal treatment outcomes.

A. The client advances the weaker leg forward to the cane. B. The client holds the cane with their left hand. C. The client takes a step with their right foot first. D. The client moves the cane 2 feet ahead.

Correct Answer is A

Explanation

A) The client advances the weaker leg forward to the cane:
Advancing the weaker leg forward to the cane demonstrates the correct use of the quad cane. This technique helps to provide support and stability, allowing the client to maintain balance while transferring weight onto the cane and weaker leg.

B) The client holds the cane with their left hand:
Holding the cane with the left hand is incorrect for a client with left-sided weakness. The cane should be held in the hand opposite the weaker side, which would be the right hand in this case, to ensure optimal balance and support.

C) The client takes a step with their right foot first:
Taking a step with the right foot first does not indicate proper use of the cane. The correct sequence involves moving the cane and the weaker leg forward together, followed by the stronger leg to maintain stability and support.

D) The client moves the cane 2 feet ahead:
Moving the cane 2 feet ahead is too far and can compromise the client’s balance. The cane should be moved a short distance, typically about 6 to 12 inches, to provide steady support and prevent falls.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assessing a client who is 4 hr. postoperative following arterial revascularization of the left femoral artery. Which of the following findings should the nurse report to the provider immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes that the weights are resting on the floor. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is teaching a client who has left-sided weakness how to use a quad cane. Which of the following client actions indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is caring for a client following a cardiac catheterization who has hives and urticaria following administration of IV contrast dye. Which of the following medications should the nurse plan to administer?

A nurse in the emergency department is monitoring a client who is receiving dopamine to treat hypovolemic shock. Which of the following findings should the nurse identify as an indication for increasing the client's dopamine dosage?

A charge nurse on a neurological unit is making room assignments for a group of clients. Which of the following clients should the nurse assign to the room closest to the nurses' station?

A nurse is caring for a client who has a spinal cord injury and has developed autonomic dysreflexia. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A nurse is planning care for a client who has a seizure disorder. Which of the following equipment should the nurse place in the client's room?

A nurse is assessing a client who has heart failure and a new prescription for metoprolol. Which of the following findings should the nurse identify as an adverse effect of the medication?

A nurse is caring for a client who is experiencing an acute asthma attack. Which of the following should the nurse identify as a contributing factor to the client's manifestations?

A nurse is caring for a client who has been prescribed an antibiotic. The client tells the nurse, "I don't like taking medications because I don't think I need them." Which of the following responses should the nurse make?