A nurse is caring for a client who has musculoskeletal injuries to the left lower extremity. Which of the following assessments should the nurse perform to evaluate the neurovascular status of the client's extremity?

Check skin temperature distal to the injury with the dorsum of the hand.

Press the heel of the foot to determine capillary refill.

Monitor sensation by palpating the pad of the great toe with a blunt needle.

Compare the color of the skin proximal to the injury with the other extremity.

Answer and Explanation

The Correct Answer is A

A. Check skin temperature distal to the injury with the dorsum of the hand.: Assessing skin temperature distal to the injury is an important part of evaluating neurovascular status. It helps to identify any changes in circulation or potential complications like ischemia. The dorsum of the hand is commonly used as it provides a good comparison to the temperature of the affected extremity.

B. Press the heel of the foot to determine capillary refill.: While capillary refill is an important assessment, it is usually measured by pressing the nail beds or pads of the fingers and toes, not by pressing the heel. This method does not provide a reliable indication of neurovascular status.

C. Monitor sensation by palpating the pad of the great toe with a blunt needle.: While assessing sensation is important, it is typically done using a light touch or pinprick, rather than palpating with a blunt needle. The use of a needle is not standard practice for this type of assessment.

D. Compare the color of the skin proximal to the injury with the other extremity.: Comparing the skin color distal to the injury with the unaffected extremity is more relevant for evaluating neurovascular status. Proximal comparison is less effective in assessing circulation and potential issues related to the injury.

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Correct Answer is B

Explanation

A) Position the cast on a plastic-covered pillow:
Positioning the cast on a plastic-covered pillow is not recommended because the plastic can trap moisture and heat, potentially affecting the cast's integrity as it dries. Instead, a soft, absorbent material should be used to support the cast.

B) Perform neurovascular checks every 2 hr:
Frequent neurovascular checks are essential to monitor for complications such as compartment syndrome, nerve damage, or impaired circulation. This action helps ensure that any changes in sensation, movement, or circulation are identified and addressed promptly.

C) Instruct the client to avoid moving the fingers on the left hand:
Encouraging the client to move their fingers is important to prevent stiffness and swelling and to promote circulation. Instructing the client to avoid moving their fingers is not appropriate and could lead to complications.

D) Touch the cast with the palms of the hands when moving the client:
Handling a wet plaster cast with the palms of the hands is correct to prevent indentations and pressure points that could cause skin irritation or pressure sores. However, this action is not as critical as performing frequent neurovascular checks to ensure the client's safety and monitor for complications.

A. Drowsiness B. Diminished patellar reflexes C. Generalized muscle weakness D. Bradycardia

Correct Answer is D

Explanation

A) Drowsiness: While drowsiness can be a symptom of elevated magnesium levels, it is not the most critical finding to report immediately. Drowsiness can be observed with other conditions as well.

B) Diminished patellar reflexes: This can be indicative of hypermagnesemia, but it is a less immediate concern compared to other symptoms. Monitoring reflexes is important, but not the priority.

C) Generalized muscle weakness: Muscle weakness is a common symptom of elevated magnesium levels, but it is less urgent compared to cardiac issues. Although important, it does not pose an immediate risk like bradycardia.

D) Bradycardia: Elevated magnesium levels can cause serious cardiac complications, including bradycardia. This can be life-threatening and requires prompt attention to prevent severe outcomes, making it the priority to report to the provider.

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A nurse is caring for a client who has musculoskeletal injuries to the left lower extremity. Which of the following assessments should the nurse perform to evaluate the neurovascular status of the client's extremity?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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