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 B
Explanation
Choice A reason
While thinning of secretions can be a positive sign, it's not always visible. A decrease in peak inspiratory pressure is a more objective indicator of improved airway patency.
Choice B reason.
Peak inspiratory pressure is the maximum pressure required to push air into the lungs. If suctioning is effective, it will remove secretions and reduce airway resistance, leading to a decrease in peak inspiratory pressure.
Choice C reason:
While a productive cough can indicate that secretions are being moved, it doesn't directly measure the effectiveness of suctioning.
Choice D reason:
Flattening of the artificial airway cuff: Flattening of the artificial airway cuff is not a relevant indicator of the effectiveness of suctioning. The cuff of an endotracheal tube is inflated to prevent air leaks around the tube and to maintain proper ventilation. It is not directly related to the effectiveness of suctioning.
Correct Answer is A
Explanation
Choice A reason:
A. Natal Infant Pain Scale (NIPS): The NIPS is a behavioral assessment tool designed for both preterm and full-term neonates. It evaluates six behavioral indicators in response to painful procedures. These indicators include changes in facial expression (such as grimacing, brow bulge, and eye squeeze), body movements (such as fisting, tremulousness, and limb withdrawal), and other signs of distressChoice B reason:
FACES pain rating scale The FACES pain rating scale should not be used because it is a visual scale that uses facial expressions to assess pain in children who can communicate using pictures of faces displaying different emotions. It is generally used for older children and not appropriate for newborns.
Choice C reason
Premature Infant Pain Profile (PIPP): The PIPP is another pain assessment tool specifically developed for preterm infants. It considers physiological and behavioral parameters, including facial expressions, heart rate, oxygen saturation, and gestational age. While useful for preterm infants, it may not be the best choice for full-term newborns.Since the newborn in this scenario was delivered at 38 weeks of gestation, the PIPP would be an appropriate pain assessment tool to use. It considers specific physiological and behavioural indicators of pain in newborns and helps healthcare providers evaluate and manage pain in this vulnerable population.
Choice D reason:
Visual analog scale (VAS) should not be used because the visual analog scale is a pain assessment tool typically used for older children, adolescents, and adults who can understand and provide a subjective rating of their pain intensity along a linear scale. It involves marking a point on the line corresponding to the level of pain experienced. Since newborns cannot communicate in this way, the VAS is not suitable for their pain assessment.
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