A nurse is assisting in the care of a client who is in the emergency department (ED) following a ski accident.
The nurse is collecting data on the client. Which of the following findings require follow up?
Select all that apply.
Findings of right lower extremity assessment
Pain level
Level of consciousness
Oxygen saturation
Right pedal pulses
Temperature
X-ray results
Correct Answer : A,B,E
A. Findings of right lower extremity assessment: The diminished pulses, cool temperature, and reduced sensation of the right foot suggest impaired circulation and potential compartment syndrome, which is an emergency.
B. Pain level: A pain level of 10/10 that is disproportionate to the injury indicates a need for immediate evaluation, as it may signal compartment syndrome.
C. Level of consciousness: Not concerning as the client is alert and denies loss of consciousness.
D. Oxygen saturation: Normal at 97%.
E. Right pedal pulses: A diminished pedal pulse (1+) on the right is a critical finding that requires urgent intervention to restore circulation.
F. Temperature: A temperature of 36°C is within normal limits and does not require follow-up.
G. X-ray results: Confirms the fracture but is not a finding requiring immediate follow-up compared to circulatory concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "There is no cure for MRSA.": MRSA infections can be treated with specific antibiotics.
B. "We will need to wear masks when we are in the hospital room.": Masks are not necessary for contact precautions unless there is an additional indication, such as droplet precautions.
C. "MRSA only occurs in health care facilities.": MRSA can occur in both community and healthcare settings.
D. "We should remove gloves before leaving the hospital room.": Gloves and gowns must be removed inside the room to prevent contamination of the hospital environment.
Correct Answer is D
Explanation
A. Muscle spasms: These are not typically associated with DVT.
B. Absent pedal pulse: This suggests arterial occlusion, not venous thrombosis.
C. Numbness of the affected extremity: Numbness is not a classic sign of DVT and might indicate a nerve-related issue.
D. Warmth of the affected extremity. Warmth is a hallmark sign of DVT due to localized inflammation and impaired venous circulation.
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