A nurse is caring for a client who has a cast due to a compound fracture of the right ankle. Which of the following findings requires immediate intervention?
Localized stabbing pain upon movement
Pruritus under the cast
Edema present when the leg is in a dependent position
Paresthesia of the distal extremity
The Correct Answer is D
Choice A reason: Localized stabbing pain upon movement can occur with fractures and casts, but pain alone is not always an emergency unless it is severe, unrelieved, or disproportionate to the injury. Pain is expected in the healing process and can often be managed with analgesics.
Choice B reason: Pruritus under the cast is a common complaint due to skin dryness and irritation. While uncomfortable, it is not dangerous and does not require immediate intervention.
Choice C reason: Edema when the leg is in a dependent position is expected after a fracture and casting. Elevation of the limb usually helps reduce swelling. This is not an urgent finding unless swelling is severe and compromises circulation.
Choice D reason: Paresthesia of the distal extremity indicates impaired circulation or nerve compression, which can be a sign of compartment syndrome. This is a medical emergency because it can lead to permanent nerve and muscle damage if not treated promptly. Immediate intervention is required, making this the correct answer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Cleansing the insertion site daily is not appropriate because frequent manipulation increases the risk of introducing pathogens into the epidural space. The site should be maintained with sterile technique and minimal disturbance to reduce infection risk.
Choice B reason: Covering the insertion site with a transparent dressing is appropriate because it allows continuous visualization of the site for signs of infection or leakage while maintaining sterility. Transparent dressings also reduce the need for frequent manipulation, thereby lowering infection risk.
Choice C reason: Administering supplemental opioids without provider orders is unsafe. Epidural analgesia is tightly regulated, and additional opioids could increase the risk of respiratory depression, sedation, and overdose.
Choice D reason: Replacing infusion tubing every 72 hours is standard for IV therapy but not specific to epidural analgesia. Epidural tubing requires specialized sterile handling and should not be routinely changed unless clinically indicated.
Correct Answer is B
Explanation
Choice A reason: Asking a family member to translate is inappropriate because family members may lack medical knowledge, misinterpret information, or withhold sensitive details. This compromises accuracy and confidentiality.
Choice B reason: Using a telephone medical interpreter service ensures accurate, professional translation of medical information. Medical interpreters are trained to convey complex terminology and maintain confidentiality, making this the correct action.
Choice C reason: Assistive personnel may not be trained in medical interpretation. Even if they speak the language, they may misinterpret medical terminology, leading to errors in client understanding.
Choice D reason: The nurse should direct all information to the client, not the interpreter. The interpreter’s role is to facilitate communication, but maintaining eye contact and addressing the client directly preserves therapeutic rapport and respect.
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