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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale:
Allergy to eggs is not a contraindication for taking chondroitin with glucosamine. These supplements do not contain eggs and are generally safe for individuals with egg allergies.
Choice B rationale:
Hypotension is not directly related to the use of chondroitin with glucosamine. These supplements are not known to cause significant changes in blood pressure.
Choice C rationale:
History of hypoglycemia is not a specific concern with chondroitin and glucosamine supplements. These supplements do not significantly impact blood sugar levels in people without diabetes.
Choice D rationale:
The correct choice. The nurse should instruct the client to use chondroitin with glucosamine with caution if they are on anticoagulant therapy. Chondroitin and glucosamine may have mild anticoagulant effects, and when combined with prescribed anticoagulant medications, there is a potential risk of increased bleeding or altered blood clotting times. It is essential to monitor the client's coagulation parameters closely if they decide to use these supplements.

A. Instruct the client to take deep breaths during the test. B. Assist the client to a prone position prior to the test. C. Inform the client that the new onset of a cough is expected following the test. D. Apply pressure to the client's puncture site after the test is complete.

Correct Answer is D

Explanation

Choice A rationale:

Instructing the client to take deep breaths during the test is not appropriate for a thoracentesis. This procedure involves the insertion of a needle into the pleural space to drain fluid or air, and taking deep breaths could interfere with the accuracy and safety of the procedure.

Choice B rationale:

Assisting the client to a prone position prior to the test is also incorrect. During a thoracentesis, the client is usually seated upright or in a slightly forward-leaning position to allow better access to the pleural space and improve breathing.

Choice C rationale:

Informing the client that the new onset of a cough is expected following the test is not accurate. While a cough can be a possible side effect, it is not a common or expected outcome of a thoracentesis.

Choice D rationale:

Applying pressure to the client's puncture site after the test is complete is the correct action. This helps to prevent bleeding and reduce the risk of pneumothorax (collapsed lung) by promoting clot formation at the site of the needle insertion.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is caring for a client who is scheduled for diagnostic thoracentesis. Which of the following actions should the nurse take when assisting with this test?

Correct Answer is D

Explanation

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