A nurse is collecting data from a client who is experiencing delirium. Which of the following findings should the nurse expect?

Choice A reason: Diminished pulses signal compromised circulation, a critical cast complication like compartment syndrome. This risks tissue necrosis or amputation if untreated, prioritizing it scientifically, as arterial flow disruption demands immediate intervention to preserve limb viability per vascular assessment standards.

Choice B reason: Ecchymosis suggests bruising, possibly from cast pressure, but isn’t immediately life-threatening like poor circulation. It’s a secondary concern, manageable later. Scientifically, it indicates trauma, not acute vascular emergency, ranking lower in urgency per cast complication protocols.

Choice C reason: Muscle spasms may indicate irritation or pressure, but they’re less urgent than absent pulses. Pain is common in casts, not always critical. Scientifically, this suggests nerve or muscle stress, not imminent tissue loss, making it a lower priority for immediate action.

Choice D reason: One fingerbreadth space is normal, preventing tightness, not a concern. It’s ideal fit, not a problem. Scientifically, this aligns with safe cast application, lacking urgency compared to circulatory threats, as it supports, rather than jeopardizes, limb health.

Choice A reason: Applying suction while inserting risks trauma to nasal mucosa, as continuous pressure can tear delicate tissues or cause bleeding. Proper technique involves inserting without suction, then applying it on withdrawal to safely remove secretions, minimizing injury and ensuring effective clearance without damaging the airway lining.

Choice B reason: Intermittent suction for 30 seconds exceeds safe limits; guidelines recommend 10-15 seconds to avoid hypoxia. Prolonged suction depletes oxygen in the airway, especially in nasopharyngeal suctioning, where ventilation is obstructed, risking respiratory distress or cardiac complications in an adult client with compromised breathing.

Choice C reason: Inserting the catheter 10 cm (4 in) is too shallow for nasopharyngeal suctioning in adults, where 16-20 cm reaches the pharynx. Insufficient depth fails to clear secretions effectively, leaving mucus in lower airways, potentially worsening obstruction or infection, as the catheter must target the secretion source accurately.

Choice D reason: Waiting 1 minute between attempts allows oxygen levels to stabilize, preventing hypoxia during nasopharyngeal suctioning. This interval ensures the client reoxygenates after airway occlusion, reducing risks of desaturation or arrhythmia, aligning with safe practice to maintain respiratory stability while clearing mucus effectively in adults.