A nurse is performing a neurovascular assessment on a client who has a fractured left femur. For which of the following findings should the nurse intervene immediately?
Left leg is warm to the touch.
Left pedal pulse strength is 2.
The client reports pain in the foot of the left leg.
Capillary refill in the left foot is 3 seconds.
The Correct Answer is D
Choice A rationale:
A warm left leg is a normal finding and does not require immediate intervention. Warmth indicates adequate circulation to the limb.
Choice B rationale:
A pedal pulse strength of 2 in the left leg indicates diminished pulse but does not require immediate intervention. The nurse should continue to monitor the pulse and report any significant changes to the healthcare provider.
Choice C rationale:
The client's report of pain in the foot of the left leg is an expected finding due to the fractured left femur. Pain is a subjective symptom, and the nurse should address the client's pain appropriately but not intervene immediately based on this finding.
Choice D rationale:
This is the correct choice. A capillary refill time of 3 seconds in the left foot suggests impaired circulation, which could be indicative of compartment syndrome or other circulation-related issues. The nurse should intervene immediately by notifying the healthcare provider to prevent further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
The statement "If I can keep my hemoglobin A1C less than 6.5%, I will be cured of diabetes.”. is incorrect. While maintaining an A1C level below 6.5% is a recommended target for some individuals with diabetes, achieving this level does not cure diabetes. Diabetes is a chronic condition that requires ongoing management and lifestyle modifications.
Choice B rationale:
Checking blood sugar levels before exercising is an important aspect of managing type 1 diabetes. Exercise can affect blood glucose levels, and knowing the current level helps the client determine whether it is safe to engage in physical activity or if adjustments to insulin or carbohydrate intake are needed.
Choice C rationale:
Having regular eye checks every 2 years is essential for clients with diabetes, but it is not the best statement that indicates an understanding of health promotion activities for a new diagnosis of type 1 diabetes mellitus.
Choice D rationale:
Soaking feet daily in warm, soapy water is not a recommended practice for clients with diabetes. It can lead to skin dryness and increase the risk of infection. Instead, clients with diabetes should practice daily foot inspections and keep their feet moisturized to prevent complications related to peripheral neuropathy.
Correct Answer is D
Explanation
Choice A rationale:
Poor skin turgor is a sign of dehydration and is not specifically related to hypoglycemia. It is assessed by pinching the skin on the back of the hand and observing how quickly it returns to its normal position.
Choice B rationale:
Fruity breath odor is associated with diabetic ketoacidosis (DKA), a complication of uncontrolled diabetes, not hypoglycemia. It is caused by the presence of ketones in the breath due to the breakdown of fats for energy in the absence of adequate insulin.
Choice C rationale:
Kussmaul respirations are deep, rapid, and labored breathing patterns seen in diabetic ketoacidosis (DKA), not in hypoglycemia. They are the body's attempt to blow off excess carbon dioxide and acid from the blood.
Choice D rationale:
Irritability is a common manifestation of hypoglycemia. Low blood glucose levels can affect brain function, leading to mood changes, irritability, and nervousness.
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