A nurse is evaluating a client who has impaired mobility after receiving casting on their legs bilaterally. Which of the following findings requires Intervention by the nurse?
Oral temperature 37.8° C (100 F)
Client can wiggle their toes
Feet warm to the touch
Pedal pulses +1
The Correct Answer is D
A. Oral temperature 37.8° C (100.0° F): A mild fever (37.8° C) could be a normal response to trauma or stress, especially following casting. It does not necessarily indicate an urgent issue, but it should be monitored, particularly if it increases or persists.
B. Client can wiggle their toes: The ability to move the toes is a positive sign that the neurovascular function of the extremities is intact. This is reassuring and indicates that circulation and nerve function are being maintained.
C. Feet warm to the touch: Warm feet suggest that there is adequate blood circulation to the extremities. This is a positive finding and does not require intervention unless other signs of complications arise.
D. Pedal pulses +1: A +1 pulse indicates weak pulses, which is concerning after casting. It may be a sign of reduced circulation, and the nurse should assess for further complications such as compartment syndrome, which can result in inadequate blood flow and tissue damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Serosanguineous drainage: Serosanguineous drainage, which is a mixture of serum and blood, is common and expected in the early stages of wound healing, including stage 3 pressure injuries. It does not necessarily indicate infection.
B. Granulation tissue: Granulation tissue is a sign of healthy wound healing. It appears as red, moist tissue and indicates that the wound is healing properly, so it does not suggest infection.
C. Localized tenderness: Localized tenderness around the wound can be a sign of infection. Infection can cause pain, redness, warmth, and tenderness at the site of the pressure injury. It is important to monitor for other signs of infection, such as increased drainage or changes in wound color.
D. Moist wound bed: A moist wound bed is generally beneficial for wound healing and does not indicate infection. In fact, keeping the wound moist helps promote granulation tissue formation and wound closure.
Correct Answer is B
Explanation
A. Hgb 11.5 g/dL (12 to 16 g/dL): While this hemoglobin level is slightly below normal, it is not an immediate priority compared to other more concerning values. Anemia could be addressed later with appropriate interventions but is not life-threatening in this case.
B. Creatinine 3.2 mg/dL (0.5 to 1.1 mg/dL): A creatinine level of 3.2 mg/dL is significantly elevated and indicates possible kidney dysfunction or acute kidney injury. Gentamicin is known to be nephrotoxic, and this level requires prompt attention to prevent further renal damage.
C. Sodium 146 mEq/L (136 to 145 mEq/L): Sodium levels are only slightly elevated and do not represent an immediate concern unless the client has symptoms of hypernatremia (e.g., confusion, seizures). While monitoring is required, it is not as urgent as the creatinine.
D. WBC count 12,000/mm3 (5,000 to 10,000/mm3): A WBC count of 12,000/mm3 is mildly elevated, which could suggest an infection or inflammation. However, this is not the priority compared to the kidney function, which could be compromised by gentamicin therapy.
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