A nurse is caring for a client who has a fractured arm in a cast. Which of the following findings about the affected arm should the nurse report to the provider?
Active movement is present
Pain is 4 on scale of 0 to 10
Capillary refit is less than 2 seconds
Skin is cool to the touch
The Correct Answer is D
A. Active movement is present: The presence of active movement in the fingers and toes of the affected arm indicates that nerve and muscle function are intact, which is a positive finding. It indicates there is no impairment in function of the affected arm.
B. Pain is 4 on scale of 0 to 10: A pain level of 4 is moderate pain and might be expected after a fracture. As long as pain is being managed appropriately with prescribed medications and no other concerning symptoms are present, it does not necessarily require immediate reporting.
C. Capillary refill is less than 2 seconds: A capillary refill time of less than 2 seconds is normal. This suggests good blood flow to the affected arm and is not an issue that needs reporting.
D. Skin is cool to the touch: A cool skin temperature on the affected arm could indicate impaired circulation, possibly due to swelling or tightness of the cast, which could lead to compartment syndrome—a serious condition that requires immediate intervention. Therefore, this finding should be reported to the provider immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Check the water temperature with your finger": Checking water temperature with a finger is unreliable because fingers may tolerate higher temperatures without discomfort. It is recommended to use the inside of the wrist or a thermometer to ensure the water is warm but not hot, typically around 100°F (37.8°C), to prevent burns.
B. "Hold your baby under running water when washing his hair": Holding a newborn under running water is unsafe because it can cause sudden chilling, difficulty breathing, or even slipping. Instead, caregivers should use a damp, warm washcloth or gently pour water over the baby's head while securely supporting it.
C. "Cleanse the eyes from the inner canthus outward": Cleaning from the inner to the outer canthus is correct technique because it prevents introducing contaminants into the tear duct. This motion also minimizes the spread of bacteria, reducing the risk of eye infections in the delicate eyes of a newborn.
D. "Set the water heater to 125.6 degrees Fahrenheit": A water heater set to 125.6°F presents a high risk of scald burns in infants. Safety guidelines recommend setting the water heater to no higher than 120°F (48.9°C) to reduce the risk of accidental burns during bathing or household water use.
Correct Answer is B
Explanation
A. Dry skin: Dry skin is not typically associated with the disulfiram-alcohol reaction. The primary concerns involve cardiovascular and gastrointestinal symptoms rather than dermatologic effects.
B. Hypotension: Disulfiram causes an intense physical reaction when alcohol is consumed, including symptoms like flushing, nausea, vomiting, hypotension, and potentially life-threatening cardiovascular collapse. Monitoring for hypotension is critical during this reaction.
C. Constipation: Constipation is not a typical side effect of disulfiram-alcohol interaction. Gastrointestinal symptoms such as nausea and vomiting are much more common and more clinically significant.
D. Urinary retention: Urinary retention is not a known reaction to the combination of disulfiram and alcohol. The body’s response focuses more on vascular changes and gastrointestinal distress.
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