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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Numbness of the toes following a femur fracture can indicate potential nerve compromise or damage, which requires immediate attention. Nerve compression or injury can lead to long-term complications if not addressed promptly. It is important for the nurse to assess the client's neurovascular status, including circulation, sensation, and movement, to determine if there is any compromise to the affected limb.
A client with cirrhosis and severe pruritus can be seen next, as pruritus can significantly affect the client's comfort and quality of life. However, it is not immediately life-threatening.
A client who had a renal biopsy 3 hours ago and has pink-tinged urine should be assessed, but this finding is expected after a renal biopsy. The nurse should ensure that the client is monitored for any signs of bleeding or complications, but it may not require immediate attention unless the bleeding worsens or other concerning symptoms arise.
A client who had a laparoscopic appendectomy 8 hours ago and is awaiting discharge can be seen last, as long as there are no complications or signs of postoperative issues. The nurse should ensure that the client is stable, comfortable, and meeting the necessary criteria for discharge.
Correct Answer is B
Explanation
b. Increased urinary output.
Furosemide is a diuretic medication that helps remove excess fluid from the body by increasing urine production and output. In a client with heart failure, one of the indicators that the medication is effective is an increase in urinary output. This can help reduce fluid buildup in the body, which can improve symptoms of heart failure.
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