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:
Older adults are at increased risk for falls due to decreased vision, balance issues, and decreased reaction time. Placing white or brightly colored tape on the edges of stairs enhances visibility, reducing the risk of missteps and falls.
Choice B Reason:
Placing area rugs on wooden floors is not appropriate. Area rugs on wooden floors can pose a tripping hazard, especially for older adults who might have mobility issues. They can easily slip or trip on loose rugs. Securing rugs with non-slip backing or removing them entirely is a better safety measure.
Choice C Reason:
Running wires and cords under carpeting is not appropriate. Running wires and cords under carpeting can create tripping hazards and increase the risk of electrical issues, including potential overheating and fire hazards. It's safer to secure cords along walls or use cord covers to prevent tripping and reduce potential electrical hazards
Choice D Reason:
Heating systems should be inspected annually to prevent carbon monoxide poisoning and fire hazards. An annual inspection is recommended, especially for older adults who may have impaired smell or cognition, making them less likely to detect gas leaks or heating malfunctions.
Correct Answer is B
Explanation
Choice A Reason:
The client had a hemorrhoidectomy 1 year ago is appropriate. While hemorrhoids involve bleeding in the anal area, the blood from hemorrhoids is usually visibly present and not considered "occult" or hidden. A history of hemorrhoidectomy is less likely to cause a false-positive occult blood test result as the bleeding is typically visible.
Choice B Reason:
The client takes ibuprofen for headaches is correct. Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can irritate the gastrointestinal tract, leading to small amounts of bleeding. This bleeding, although not typically visible, can be detected by occult blood tests, resulting in a false-positive result
Choice C Reason:
The client has a history of breast cancer is incorrect. A history of breast cancer, in itself, is not directly related to gastrointestinal bleeding that would lead to a false-positive result in an occult blood test. Occult blood screening tests primarily detect bleeding from the gastrointestinal tract.
Choice D Reason:
The client consumed citrus juice 3 days before the test is incorrect. Consumption of citrus juice is not known to cause false-positive results in occult blood screening tests. These tests are designed to detect blood specifically from the gastrointestinal tract and aren't affected by citrus juice consumption.
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