A nurse is assessing for early signs of compartment syndrome for a client who has a short-leg fiberglass cast. Which of the following findings should the nurse expect?

Intense pain with movement

Bounding distal pulses

Erythema of the toes

Capillary refill less than 2 seconds

Answer and Explanation

The Correct Answer is A

Compartment syndrome is a condition in which increased pressure within a confined space compromises blood flow and tissue perfusion, leading to ischemia and necrosis. It can occur after trauma, fracture, or casting of an extremity. The early signs of compartment syndrome include intense pain with movement that is not relieved by analgesics or elevation, paresthesia, pallor, and decreased sensation and motor function of the affected limb. The late signs include absent distal pulses, cyanosis, coldness, and paralysis. Therefore, option A is correct.

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Correct Answer is C

Explanation

Palpating the site for a thrill is an important action to assess the patency and function of an arteriovenous graft, which is a synthetic tube that connects an artery and a vein for hemodialysis access. A thrill is a vibration felt over the graft that indicates blood flow. The other options are incorrect because they could compromise or damage the graft.

A. Decrease time spent outdoors. B. Limit engaging in sport activities that can cause bruising. C. Decrease intake of fresh fruits or vegetables. D. Limit socializing in large crowds.

Correct Answer is B

Explanation

The nurse should instruct the clients to limit engaging in sport activities that can cause bruising, as radiation therapy can cause thrombocytopenia and increase the risk of bleeding. The nurse should also encourage the clients to increase their fluid intake, eat a balanced diet that includes fresh fruits and vegetables, and protect their skin from sun exposure. The nurse should not advise the clients to limit socializing in large crowds, unless they have a low white blood cell count and are at risk of infection.

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A nurse is assessing for early signs of compartment syndrome for a client who has a short-leg fiberglass cast. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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