A nurse is collecting data from a client who has a long leg cast on his left leg. Which of the following findings is the priority?

Ecchymosis on the inner left thigh

One fingerbreadth of space between the cast and the skin

Diminished pulses on the aﬀected extremity

Client report of muscle spasms of the left leg

Answer and Explanation

The Correct Answer is C

c. Diminished pulses on the aﬀected extremity. This finding may indicate compromised circulation, which is

a serious complication that requires immediate intervention.

Option a. Ecchymosis on the inner left thigh may be a concerning finding, but it is not as urgent as diminished pulses. Ecchymosis may be a result of trauma during cast application, and may resolve on its own.

Option b. One fingerbreadth of space between the cast and the skin is a normal finding and indicates that the cast is not too tight.

Option d. Client report of muscle spasms of the left leg is a common complaint in clients with casts and may

be addressed with medication or other interventions, but it is not as urgent as diminished pulses. Therefore, the priority finding in this scenario is c. Diminished pulses on the aﬀected extremity.

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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}

Explanation

The client's symptoms are concerning for angina or a possible myocardial infarction (heart atack) and require immediate intervention. Nitroglycerin is a medication that can help relieve chest pain associated with cardiac events by dilating blood vessels and reducing the workload on the heart.

Therefore, the nurse should administer nitroglycerin as ordered by the provider. After administering nitroglycerin, the nurse should obtain an ECG to assess for any changes in cardiac rhythm or evidence of ischemia (lack of blood ﬂow to the heart muscle).

The ECG can provide important diagnostic information and guide further treatment decisions.

A. Restrict the client's sodium intake to 3 g per day. B. Position the client supine with legs elevated. C. Measure the client's abdominal girth daily. D. Keep the client's daily protein intake below 0.8 g/kg.

Correct Answer is C

Explanation

A.Sodium restriction is a key component in the management of ascites, as it helps to reduce fluid retention. However, the standard recommendation for sodium intake in ascites management is typically lower than 3 grams per day. The guideline is often around 2 grams or even less to effectively manage ascites. Thus, while the concept is correct, the specific amount in this option is slightly higher than usually recommended.

B.This is not generally recommended for clients with ascites. Lying flat can increase discomfort and pressure on the diaphragm, making breathing more difficult. Instead, positioning the client in a semi-Fowler's or Fowler's position can help alleviate respiratory distress by reducing pressure on the diaphragm.

C. This is a crucial intervention. Measuring abdominal girth daily provides a reliable way to monitor changes in the size of the abdomen, which reflects changes in the amount of ascitic fluid. It helps in assessing the effectiveness of treatment and detecting any rapid accumulation of fluid that might require intervention.

D.While protein restriction was traditionally recommended to prevent hepatic encephalopathy, more recent guidelines suggest that moderate protein intake should be maintained unless the client has severe hepatic encephalopathy. Adequate protein intake is necessary to prevent muscle wasting and support liver function, and it should generally be individualized based on the client’s condition.

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A nurse is collecting data from a client who has a long leg cast on his left leg. Which of the following findings is the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client. Exhibits Complete the following sentence. After notifying the provider, the nurse should first and then . (Separate your answers with a comma ',')

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}

Explanation

A nurse is contributing to the plan of care for a client who has ascites due to cirrhosis. Which of the following interventions should the nurse recommend to include in the plan?

Correct Answer is C

Explanation

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