A nurse is collecting data from a client who had a long arm cast applied 2 hr. ago. Which of the following findings of the affected extremity should the nurse report to the provider immediately?
The client's fingers are cool to the touch.
The client reports severe itching under the cast.
The client's capillary refill is 3 seconds.
The client reports increased pain at the area of the fracture.
The Correct Answer is A
Choice A Reason:
The client's fingers are cool to the touch is correct. Coolness of the fingers within a short time after a cast application can indicate compromised circulation or potential compartment syndrome, which requires urgent attention to prevent tissue damage or loss of function. It suggests impaired blood flow to the fingers, which is a serious concern requiring immediate evaluation by the provider.
Choice B Reason:
The client reports severe itching under the cast is incorrect. While itching can be uncomfortable, it might not pose an immediate threat. Itching can commonly occur as the skin heals and can be managed through non-invasive means.
Choice C Reason:
The client's capillary refill is 3 seconds is incorrect. A capillary refill of 3 seconds is slightly prolonged but doesn't typically indicates an immediate emergency. However, if this finding worsens or if combined with other concerning symptoms, it might warrant further assessment.
Choice D Reason:
The client reports increased pain at the area of the fracture is incorrect. Increased pain after a cast application can be expected initially, especially within 2 hours of the procedure. However, persistent or severe pain could indicate issues like poor alignment, swelling, or other complications. While it's important to address pain, it might not require immediate reporting unless accompanied by other concerning symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason;
"You should consume small, frequent meals each day." This statement is advisable for COPD management. Eating smaller, more frequent meals can help prevent bloating or feeling overly full, which might interfere with breathing due to increased pressure on the diaphragm.
Choice B Reason:
"You should decrease your caloric intake by 200 calories per day." While maintaining a healthy weight is important for COPD management, reducing caloric intake without specific guidance or assessment might not be suitable. It's crucial to consult with a healthcare provider or dietitian for individualized dietary recommendations.
Choice C Reason:
"You should increase your oxygen to 5 liters per minute if you have shortness of breath." Adjusting oxygen flow should be done based on a healthcare provider's prescribed guidelines. Self-adjustment of oxygen flow without medical advice can be risky and might not address the underlying cause of shortness of breath during a COPD exacerbation.
Choice D Reason:
"You should discontinue your prednisone when your symptoms improve." Prednisone or other corticosteroids are often prescribed during a COPD exacerbation to reduce inflammation in the airways. However, discontinuing corticosteroids abruptly without a healthcare provider's guidance can lead to a recurrence of symptoms or potential complications. It's important to follow the prescribed regimen and complete the course as directed.
Correct Answer is D
Explanation
Choice A Reason:
Positive Trousseau's sign is incorrect. Trousseau's sign is associated more with calcium imbalances, particularly hypocalcemia, and is assessed by inflating a blood pressure cuff on the arm to induce carpal spasm. It's not a specific indicator of metabolic acidosis related to high glucose levels in diabetes mellitus.
Choice B Reason:
Dizziness upon standing is incorrect. Dizziness upon standing, also known as orthostatic hypotension, is more commonly associated with blood pressure changes upon position changes. While it can occur in various conditions, it's not a specific indicator of metabolic acidosis in this context.
Choice C Reason:
Tingling of the fingers is incorrect. Tingling sensations, known as paresthesia, can occur due to various reasons, including nerve damage related to chronic high blood sugar levels in diabetes (diabetic neuropathy). However, it's not a direct and specific indicator of metabolic acidosis caused by high glucose levels in diabetes mellitus.
Choice D Reason:
Increased respiratory rate is correct. Metabolic acidosis in a diabetic individual can trigger compensatory mechanisms, such as increased respiratory rate (Kussmaul respirations), as the body tries to eliminate excess acids through respiration to help regulate the acid-base balance. This increased respiratory rate is an attempt to blow off carbon dioxide (a potential acidic byproduct) and decrease the acidity in the blood.
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