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 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.
Correct Answer is A
Explanation
"I changed the floor plan of our home to accommodate my father's wheelchair.”.
Choice A rationale:
This statement indicates acceptance of the role change as a caregiver for the aging parents. Making changes to the home to accommodate the father's wheelchair demonstrates the client's willingness to adapt and provide a suitable environment for caregiving.
Choice B rationale:
Feeling stressed out and overwhelmed does not necessarily indicate acceptance of the role change. It may reflect the challenges and emotional burden that come with caregiving but does not necessarily signify acceptance.
Choice C rationale:
Expressing frustration with caregiving does not necessarily indicate acceptance of the role change. It is normal to feel frustrated at times, especially when dealing with chronic illnesses, but acceptance involves embracing the responsibilities that come with the role.
Choice D rationale:
While the statement shows a willingness to learn and adapt to caregiving, it does not explicitly indicate acceptance of the role change. Acceptance involves acknowledging and embracing the new responsibilities and challenges fully.
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