A nurse is monitoring a client's lower extremity following the placement of a cast earlier in the day. Which of the following findings should the nurse identify as manifestations of compartment syndrome? (Select all that apply.)

Pale-colored toes

Decreased skin turgor

Pain relieved by analgesia

Diminished capillary refill

Sensation of tingling

Answer and Explanation

Correct Answer : A,D,E

A. Pale-colored toes are a sign of compromised circulation, which is a key manifestation of compartment syndrome. Decreased blood flow to the affected limb can cause pallor, which requires immediate intervention to prevent permanent damage.

B. Decreased skin turgor is incorrect. Skin turgor is an indicator of hydration status and is not directly related to compartment syndrome.

C. Pain relieved by analgesia is incorrect. One of the hallmark signs of compartment syndrome is severe pain that is not relieved by analgesia and worsens with passive movement.

D. Diminished capillary refill is correct. Delayed capillary refill (longer than 2 seconds) suggests poor perfusion, which can indicate increased pressure within the compartment.

E. Sensation of tingling is correct. Paresthesia (tingling or numbness) is an early sign of nerve compression due to swelling within the compartment. If untreated, this can progress to permanent nerve and muscle damage.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Applies suction during catheter removal: This is correct. Suction should only be applied when the catheter is being inserted into the tracheostomy, not when it is being removed. Applying suction during removal can cause trauma to the airway and disrupt the patient's airway integrity.

B. Suctions for 30 seconds: Suctioning for 30 seconds is generally within the recommended limit for suctioning. Prolonged suctioning can lead to hypoxia and other complications, but 30 seconds is a safe duration for most patients.

C. Preoxygenates with 100% oxygen: This is correct practice. Preoxygenating the patient before suctioning is important to avoid hypoxia, especially in patients with respiratory concerns.

D. Auscultates breath sounds: This is good practice. Auscultating breath sounds before and after suctioning helps assess the patient's respiratory status and can guide the nurse in evaluating the need for suctioning.

A. Keep track of how long it takes to complete certain tasks. B. Delegate collection of vital signs to the assistive personnel on the team. C. Make a priority to-do list at the beginning of the shift. D. Plan a time at the end of the shift to document nursing interventions. E. Complete activities with one client before moving to another client.

Correct Answer is ["A","B","C","E"]

Explanation

A. Keep track of how long it takes to complete certain tasks is correct. Tracking the time it takes to complete tasks can help the nurse identify areas for improvement and prioritize tasks accordingly.

B. Delegate collection of vital signs to the assistive personnel on the team is correct. Delegating tasks such as vital sign monitoring to assistive personnel allows the nurse to focus on higher-level clinical duties and improves time management.

C. Make a priority to-do list at the beginning of the shift is correct. Creating a to-do list helps the nurse organize tasks based on urgency, improving overall time management and ensuring critical tasks are addressed.

D. Plan a time at the end of the shift to document nursing interventions is incorrect. Documentation should be done throughout the shift as interventions are performed, not solely at the end. Delaying documentation can lead to errors and missed information.

E. Complete activities with one client before moving to another client is correct. Focusing on one client at a time helps ensure each task is completed thoroughly and reduces the risk of neglecting important care steps.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is monitoring a client's lower extremity following the placement of a cast earlier in the day. Which of the following findings should the nurse identify as manifestations of compartment syndrome? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is observing a newly licensed nurse perform suctioning for a client who has a tracheostomy. For which of the following actions by the newly licensed nurse should the charge nurse intervene?

Correct Answer is A

Explanation

A nurse is assisting with the care of a group of clients. Which of the following actions should the nurse take to manage her time effectively? (Select all that apply.)

Correct Answer is ["A","B","C","E"]

Explanation

A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?

A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls. Which of the following fall precautions should the nurse plan to implement first?

A nurse is reviewing the medical record of a client who is at 37 weeks of gestation and has HELLP syndrome. Which of the following laboratory findings should the nurse expect?

A nurse is collecting data from a client about range-of-motion for various joints. Which of the following should the nurse identify as an example of a ball and socket joint?

A nurse is reinforcing teaching with a newly licensed nurse about transcribing medication prescriptions. Which of the following prescriptions should the newly licensed nurse identify as an accurate transcription?

A nurse is reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures?

A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?

A nurse is reinforcing teaching about hand hygiene with a newly licensed nurse. Which of the following information should the nurse include in the teaching?