A nurse is caring for a client who has a new short-leg cast on his lower leg to treat an ankle fracture. Which of the following findings requires immediate notification of the provider?

Ecchymosis of the distal foot

Dependent edema distal to the cast

Moderate level of pain

Inability to flex the toes of the casted foot

Answer and Explanation

The Correct Answer is D

A. Ecchymosis of the distal foot may be expected after the application of a cast and is not necessarily an immediate concern unless it is severe or rapidly worsening.

B. Dependent edema distal to the cast can occur as a normal response to immobilization. It is not an immediate concern unless it is severe or associated with other concerning symptoms.

C. A moderate level of pain can be expected after the application of a cast. It should be managed appropriately, but it is not an immediate concern unless it is severe or uncontrolled.

D. Inability to flex the toes of the casted foot suggests a potential issue with circulation or nerve function, which requires immediate notification of the provider.

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Correct Answer is A

Explanation

A. Placing a bath seat in the shower is a safety measure to prevent falls while bathing. This statement indicates an understanding of the importance of bathroom safety.

B. Placing an area rug at the entry of the bathroom can actually increase the risk of falls, as rugs can be tripping hazards. This statement does not demonstrate an understanding of home safety.

C. Keeping the walker at the end of the bed is a good practice for easy access, but it doesn't specifically address fall prevention in the home.

D. Keeping the fluorescent ceiling light on at night can provide better visibility and reduce the risk of tripping, but it doesn't address specific fall prevention measures elsewhere in the home.

A. Remove the elastic bandage and re-wrap the stump once per day. B. Secure the elastic bandage to the lowest joint. C. Wrap the stump with an elastic bandage in a figure-eight configuration. D. Perform passive range-of-motion exercises once daily.

Correct Answer is C

Explanation

A. Remove the elastic bandage and re-wrap the stump once per day: This is not recommended. The elastic bandage provides support and helps reduce swelling. It should only be removed and re-wrapped as directed by the healthcare provider.

B. Secure the elastic bandage to the lowest joint: The bandage should be secure, but it should not be tied too tightly or secured directly over a joint. This could restrict blood flow and cause discomfort.

C. Wrap the stump with an elastic bandage in a figure-eight configuration: This is the correct action. A figure-eight configuration helps distribute pressure evenly, providing support and reducing the risk of edema and complications.

D. Perform passive range-of-motion exercises once daily: Range-of-motion exercises are important, but they should be performed within the parameters set by the healthcare provider. They should not be performed only once daily, and it's essential to avoid overexertion or straining the residual limb.

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A nurse is caring for a client who has a new short-leg cast on his lower leg to treat an ankle fracture. Which of the following findings requires immediate notification of the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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