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","B","C"]
Explanation
A. Assess peripheral circulation hourly. This is correct because clients with SCD are at risk of vaso-occlusive crisis, which can impair blood flow to the extremities and cause tissue ischemia and necrosis. The nurse should monitor for signs of poor circulation such as pallor, coolness, numbness, or pain.
B. Assess the client's mouth every 8 hr. This is correct because clients with SCD are prone to oral ulcers, infections, and dental problems due to chronic anemia and reduced oxygen delivery to the oral mucosa. The nurse should inspect the mouth for lesions, bleeding, inflammation, or infection and provide oral hygiene as needed.
C. Use humidification with oxygen therapy. Administer IV fluids. This is correct because clients with SCD need adequate hydration and oxygenation to prevent sickling of red blood cells and further complications. Humidification helps moisten the airways and prevent dehydration of the mucous membranes. IV fluids help maintain fluid and electrolyte balance and reduce blood viscosity.
D. Raise the knee position on the client's bed. This is incorrect because this can impede venous return and worsen peripheral circulation. The nurse should keep the client's extremities in a neutral position and avoid tight or restrictive clothing or devices.
E. Use an automated blood pressure cuff on the client's arm. Prepare for platelet transfusion. This is incorrect because this can cause mechanical trauma to the arm and trigger a vaso-occlusive crisis. The nurse should use a manual blood pressure cuff and avoid applying pressure to the arm. Platelet transfusion is not indicated for clients with SCD unless they have thrombocytopenia or bleeding.
Correct Answer is B
Explanation
A. Chest x-ray is not correct because it is not related to valproic acid therapy or its adverse effects.
B. Serum liver enzyme levels is correct because valproic acid can cause hepatotoxicity and liver function tests should be monitored regularly.
C. ABGS is not correct because it is not indicated for valproic acid therapy or its adverse effects.
D. Urine culture and sensitivity is not correct because it is not related to valproic acid therapy or its adverse effects.
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