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 A

Explanation

Opioid medications can cause urinary retention by inhibiting the normal function of the bladder and reducing the urge to urinate. This can lead to incomplete emptying of the bladder and increased urine retention. Nurses should monitor clients receiving opioids for signs of urinary retention, such as decreased urine output, distended bladder, or discomfort in the lower abdomen.

Opioids generally cause pupil constriction (miosis) rather than dilation (mydriasis). Dilated pupils may indicate other drug use or neurological issues, but they are not a typical adverse effect of hydromorphone.

Hydromorphone is more likely to cause hypotension (low blood pressure) as an adverse effect rather than hypertension (high blood pressure).

Hydromorphone can cause respiratory depression, which is characterized by decreased respiratory rate and depth. Tachypnea (rapid breathing) is not a typical adverse effect of hydromorphone.

A. A client who had a renal biopsy 3 hr ago and has pink-tinged urine B. A client who has a femur fracture and reports numbness of the toes C. A client who has cirrhosis and severe pruritus D. A client who had a laparoscopic appendectomy 8 hr ago and is awaiting discharge

Correct Answer is B

Explanation

Numbness of the toes in a client with a femur fracture may indicate neurovascular compromise, which requires immediate attention.

It could be a sign of impaired circulation or nerve damage, and prompt assessment is needed to prevent further complications or permanent damage.

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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

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Correct Answer is B

Explanation

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