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 A

Explanation

Choice A rationale:

The client's ABG values show a pH of 7.48, PCO2 of 30 mm Hg, HCO3 of 24 mEq/L, and PaO2 of 85 mm Hg. The elevated pH and decreased PCO2 (respiratory component) suggest respiratory alkalosis. Respiratory alkalosis occurs when there is excessive ventilation, leading to a decrease in carbon dioxide levels (hypocapnia) and subsequent alkalosis.

Choice B rationale:

Respiratory acidosis is characterized by an elevated PCO2 and decreased pH. In this case, the client's PCO2 is decreased, indicating respiratory alkalosis rather than respiratory acidosis.

Choice C rationale:

Metabolic alkalosis is characterized by an elevated HCO3 (bicarbonate) level and an increased pH. The client's HCO3 level is within the normal range, making metabolic alkalosis an incorrect identification.

Choice D rationale:

Metabolic acidosis is characterized by a decreased HCO3 level and a decreased pH. The client's HCO3 level is within the normal range, ruling out metabolic acidosis as the acid-base imbalance in this case.

A. Apply clean gloves when removing the old dressing from the catheter site. B. Cleanse the area by using a circular motion beginning at the catheter site and moving outward. C. Use warm water to cleanse the catheter site. D. Place an occlusive dressing over the catheter site after cleaning.

Correct Answer is A

Explanation

Choice A rationale:
Applying clean gloves when removing the old dressing from the catheter site is essential to prevent infection and maintain an aseptic technique during peritoneal dialysis catheter care. Gloves protect both the nurse and the patient from potential contamination.
Choice B rationale:
Cleansing the area by using a circular motion beginning at the catheter site and moving outward is not the correct technique. When caring for a dialysis catheter, the nurse should cleanse the site using an outward, circular motion starting from the insertion site to minimize the risk of contamination.
Choice C rationale:
Using warm water to cleanse the catheter site is not recommended. The peritoneal dialysis catheter site should be cleaned with an appropriate antiseptic solution or disinfectant, as warm water alone may not effectively remove bacteria or prevent infections.
Choice D rationale:
Placing an occlusive dressing over the catheter site after cleaning is not the standard practice for peritoneal dialysis catheter care. Typically, a clean, dry dressing is applied to the catheter site after cleaning to keep it clean and dry, but it should not be occlusive.

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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

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Correct Answer is A

Explanation

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