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 A
Explanation
The nurse should instruct the client to obtain sterile lancets for blood glucose monitoring.
Lancets are small needles used to prick the skin to obtain a blood sample for testing blood glucose levels.
Choice B is wrong because compression stockings are not necessary for blood glucose monitoring.
Choice C is wrong because toenail clippers are not necessary for blood glucose monitoring.
Choice D is wrong because a hand mirror is not necessary for blood glucose monitoring.
Correct Answer is D
Explanation
The nurse should palpate the dorsalis pedis pulse.
This is to assess for peripheral neurovascular dysfunction, which is a potential complication of a tibial fracture.
Choice A, wrapping sterile gauze on the sharp point of the pins, is not an answer because it is not mentioned in the search results as an intervention for a client with an external fixator for a tibial fracture.
Choice B, adjusting the clamps on the fixator frame, is not an answer because it is not mentioned in the search results as an intervention for a client with an external fixator for a tibial fracture.
Choice C, maintaining the affected extremity in a dependent position, is not an answer because it is not mentioned in the search results as an intervention for a client with an external fixator for a tibial fracture.
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