A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia.
Which of the following assessment findings requires immediate intervention by the nurse?
The client's capillary refill in the left toe is 6 seconds.
The client reports a pain level of 7 on a scale from 0 to 10 at the operative site.
The client has an oral temperature of 38.3° C (100.9° F).
The client has 100 mL of blood in the closed-suction drain.
The Correct Answer is A
“The client’s capillary refill in the left toe is 6 seconds.” Capillary refill time is the time it takes for blood to return to the capillaries after pressure has been applied to the skin.
A normal capillary refill time is less than 2 seconds.
A capillary refill time of 6 seconds indicates poor blood flow to the left toe and requires immediate intervention by the nurse.
Choice B is not the correct answer because while a pain level of 7 on a scale from 0 to 10 at the operative site is concerning, it does not require immediate intervention by the nurse.
Choice C is not the correct answer because an oral temperature of 38.3° C (100.9° F) is only slightly elevated and does not require immediate intervention by the nurse.
Choice D is not the correct answer because while 100 mL of blood in a closed-suction drain may be concerning, it does not necessarily require immediate intervention by the nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse should plan to insert a large-bore nasogastric tube for a client who has upper gastrointestinal bleeding due to a peptic ulcer.
This allows for gastric lavage and can help diagnose the source of bleeding.
Choice A is wrong because a 22-gauge IV line may be too small for rapid fluid resuscitation.
Choice B is wrong because ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of gastrointestinal bleeding.
Choice C is wrong because nitroprusside is a vasodilator used to treat hypertensive emergencies and is not typically used for upper gastrointestinal bleeding.
Correct Answer is C
Explanation
“Fluid volume excess.” Bounding pulses, crackles on auscultation, and pink frothy secretions when receiving suctioning are all signs of fluid volume excess.
Fluid volume excess can occur when the heart is unable to pump blood efficiently, causing fluid to build up in the lungs.
Choice A is not the correct answer because the increased cardiac output would not cause these symptoms.
Choice B is not the correct answer because pleural effusion refers to a buildup of fluid between the layers of tissue that line the lungs and chest cavity, which would not cause these symptoms.
Choice D is not the correct answer because aspiration refers to the inhalation of food, liquid, or other substances into the lungs, which would not cause these symptoms.
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