A nurse is assessing a client who is in skeletal traction for a fractured left tibia. The nurse should identify that which of the following findings indicates altered tissue perfusion of the affected extremity?
Pain with movement of the left great toe
Faint pedal pulse of left leg
Warm skin temperature distal to pin site
Purulent drainage at the pin site
The Correct Answer is B
Choice A reason:
Pain with movement of the left great toe is incorrect finding: Pain may be expected in a client with a fractured left tibia, especially if the great toe is moved. Pain is more related to the fracture and may not specifically indicate altered tissue perfusion.
Choice B reason:
Faint pedal pulse of the left leg is correct because it indicates that the blood flow to the foot is diminished. The pedal pulse is the pulse felt on the top of the foot, and its faintness could suggest reduced arterial blood flow to the foot.
Choice C reason:
Warm skin temperature distal to the pin site is incorrect: Warm skin distal to the pin site may indicate adequate blood flow and could be a normal finding. Warmth is generally associated with increased blood flow to the area.
Choice D reason:
Purulent drainage at the pin site is incorrect. Purulent drainage at the pin site could indicate an infection, but it is not directly related to altered tissue perfusion. Infection can lead to complications, but it does not necessarily indicate reduced blood flow to the extremity
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
- Cocaine is a powerfully addictive stimulant drug that increases the levels of dopamine in the brain, which is a chemical messenger related to movement, pleasure, and motivation.
- Cocaine's effects appear almost immediately and last for a few minutes to an hour, depending on the method of use. Some of the short-term effects of cocaine include extreme happiness and energy, mental alertness, hypersensitivity to sight, sound, and touch, and irritability.
- An elevated energy level is one of the most common and noticeable effects of cocaine use, as cocaine stimulates the central nervous system and makes the user feel more alert, active, and confident¹². This effect may also lead to increased physical activity, talkativeness, or aggression.
Therefore, option A is the correct answer, while options B, C, and D are incorrect.
Option B is incorrect because a powerful craving for more cocaine is not a behavior that can be observed by others, but rather an internal feeling that the user may experience due to the addictive nature of the drug.
Option C is incorrect because high self-esteem is not a typical effect of cocaine use, as cocaine may cause paranoia or anxiety in some users.
Option D is incorrect because euphoria is not a behavior that can be observed by others, but rather an emotional state that the user may feel due to the increased dopamine levels in the brain
Correct Answer is A
Explanation
A is correct because delegating non-nursing tasks to ancillary staff allows nurses to focus on more complex and skilled tasks that require their expertise and judgment, thus improving efficiency and quality of care.
B is incorrect because stocking client rooms with extra supplies increases waste and costs, as well as clutter and infection risk.
C is incorrect because assigning dedicated equipment to each client's room reduces availability and accessibility of equipment for other clients, as well as increases maintenance and cleaning costs.
D is incorrect because changing continuous IV infusion tubing every 24 hr is not cost-effective, as it does not reduce the risk of infection significantly compared to changing it every 72 hr, according to current evidence-based practice guidelines.
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