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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is B, A, C, E, D

Explanation

Clamp the catheter tubing distal to the sampling port for 15 min. By clamping the tubing distal to the sampling port, it allows urine to accumulate in the tubing, ensuring that the urine specimen obtained is fresh and not from the stagnant urine that has been sitting in the tubing.

Wipe the sample port with an alcohol wipe and let the alcohol dry. Cleaning the sampling port with an alcohol wipe helps reduce the risk of introducing contaminants into the sample during collection, ensuring a more sterile procedure.

Attach a sterile needleless syringe to the sample port and aspirate the specimen. Using a sterile syringe prevents contamination and allows for the collection of a clean urine sample directly from the catheter tubing, maintaining the sterility of the specimen.

Empty the urine into a sterile container labeled with the client identifiers. Transferring the collected urine into a sterile container labeled with the client's identifiers ensures proper identification and handling of the specimen for laboratory analysis.

Document in the client's electronic medical record that the specimen was sent to the laboratory. Documenting in the client's medical record ensures that there is a clear record of the specimen collection, its handling, and its dispatch to the laboratory for analysis, maintaining proper documentation and continuity of care.

A. Keep both arms below the level of the client's heart. B. Limit range-of-motion exercises with the affected arm. C. Use the client's left arm to obtain blood samples. D. Obtain blood pressure readings using the client's right arm.

Correct Answer is C

Explanation

Choice A Reason:

Keeping both arms below the level of the client's heart doesn't specifically address the prevention of lymphedema and might not be necessary for this purpose.

Choice B Reason:

Limiting range-of-motion exercises with the affected arm could potentially contribute to stiffness and reduced function, but appropriate and gradual range-of-motion exercises are generally recommended to prevent lymphedema.

Choice C Reason:

Using the client's left arm to obtain blood samples is correct. Lymphedema can occur due to the disruption of lymphatic vessels during surgery, leading to the accumulation of lymph fluid. To reduce the risk of lymphedema, medical procedures or blood draws should typically avoid using the affected arm. In this case, after a right radical mastectomy, using the left arm for blood samples can help protect the compromised lymphatic system in the right arm.

Choice D Reason:

Obtaining blood pressure readings using the client's right arm is not directly related to preventing lymphedema. However, excessive pressure or trauma to the affected arm should generally be avoided to reduce the risk of lymphedema.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is obtaining a sterile urine specimen from a client who has an indwelling urinary catheter. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Correct Answer is B, A, C, E, D

Explanation

A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema?

Correct Answer is C

Explanation

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