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 C
Explanation
C, "You can begin collection of urine after discarding your first morning void."
A 24-hour creatinine clearance test is used to evaluate how well the kidneys are functioning by measuring the amount of creatinine in the blood and urine over a 24-hour period. During the test, the client is asked to discard their first morning void and then collect all urine for the next 24 hours.
Option A is incorrect because a protein-rich diet can affect the creatinine levels in the urine, which can result in inaccurate test results. Therefore, the nurse should advise the client to avoid a protein-rich diet during the collection period.
Option B is incorrect because blood glucose levels are not relevant to a 24-hour creatinine clearance test. Therefore, the nurse should not ask the client to record their blood glucose level each time they void.
Option D is incorrect because using an antiseptic towel to cleanse the perineal area can also affect the test results by introducing contaminants into the urine sample. Therefore, the nurse should advise the client to cleanse the perineal area with soap and water or an alcohol wipe.
Correct Answer is B
Explanation
The guardian's observation about the child being withdrawn since the switch of daycare providers is particularly important. It suggests a change in behavior that could potentially indicate emotional or social difficulties.
The nurse should explore this further to gather more information and assess the child's well-being in the new daycare setting. It is essential to ensure the child's emotional health and address any potential issues that may be affecting their well-being and development.
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