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:
A PaO2 value of 86 mm Hg is within the normal range (80-100 mm Hg) and does not indicate respiratory acidosis. PaO2 measures the partial pressure of oxygen in arterial blood.
Choice B rationale:
A pH of 7.4 is within the normal range (7.35-7.45) and does not indicate respiratory acidosis. The pH reflects the acidity or alkalinity of the blood.
Choice C rationale:
An HCO3 (bicarbonate) level of 16 mEq/L is within the normal range (22-28 mEq/L) and does not indicate respiratory acidosis. HCO3 is a measure of the metabolic component of the body's acid-base balance.
Choice D rationale:
This is the correct choice. A PaCO2 value of 58 mm Hg is elevated and indicates respiratory acidosis. PaCO2 measures the partial pressure of carbon dioxide in arterial blood, and an elevated value suggests the presence of excess carbon dioxide, leading to acidosis.
Correct Answer is B
Explanation
Choice A rationale:
Increased peristalsis would be a positive sign and not indicative of postoperative paralytic ileus. Increased peristalsis would mean the bowel is functioning well.
Choice B rationale:
Abdominal distension is a classic sign of postoperative paralytic ileus, where the bowel's motility is reduced or absent. This condition can lead to a buildup of gas and fluids, causing the abdomen to become distended.
Choice C rationale:
Proximal high-pitched bowel sounds can be a normal finding after surgery, but they are not indicative of paralytic ileus. They may even be heard as the bowel recovers its motility.
Choice D rationale:
Passing flatus is a positive sign, as it indicates that the bowel is working and the patient is passing gas. This is not indicative of a postoperative paralytic ileus, which is characterized by the absence of bowel movement.
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