After falling down the basement steps, a client is brought to the emergency room. X-rays confirms that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?

Increased temperature to lower extremity.

Right foot pale with sluggish capillary refill.

Circumferential edema of right foot.

Complaint of throbbing right leg pain

Answer and Explanation

The Correct Answer is B

A. Increased temperature to the lower extremity:
While increased temperature could indicate inflammation or infection, it is not as immediately concerning as impaired circulation.

B. Right foot pale with sluggish capillary refill.
This finding suggests a potential impairment in blood flow to the right foot, which could be due to complications such as compartment syndrome or impaired circulation. Compartment syndrome is a serious condition that occurs when there is increased pressure within a muscle compartment, leading to reduced blood flow. Pale color and sluggish capillary refill indicate compromised circulation and require prompt intervention to prevent further damage.

C. Circumferential edema of the right foot:
Edema is a common finding after a fracture and cast application. However, in the context of pale color and sluggish capillary refill, it may indicate increased pressure within the compartment, requiring immediate attention.

D. Complaint of throbbing right leg pain:
Pain is a common complaint after a fracture, and throbbing pain may be expected. However, the priority is to address the potential compromise in circulation indicated by the pale color and sluggish capillary refill.

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Correct Answer is A

Explanation

A. Move the client to a private room, keep the door closed, and initiate droplet precautions:
This is the correct answer. Given the client's symptoms and potential exposure to COVID-19, it is important to take infection control measures. Placing the client in a private room, keeping the door closed, and initiating droplet precautions help prevent the potential spread of the virus.

B. Start an intravenous infusion for antiviral drug to be administered for positive COVID-19 test results:
Antiviral medications are typically prescribed based on confirmed COVID-19 test results and the severity of symptoms. Starting an intravenous infusion at this stage, before test results are available, is premature and not indicated.

C. Counsel family members to monitor for illness symptoms for 2 weeks after last contact with the patient:
While it is important for family members to monitor for symptoms, the immediate concern is the isolation and testing of the symptomatic client. Contact tracing may follow, but infection control measures for the client are the priority.

D. Assist the client to recall everyone possibly exposed since onset of symptoms:
While contact tracing is important, the immediate action is to isolate the client and initiate precautions. Contact tracing can be done as part of a broader public health response but is not the initial step.

A. Assess client for signs and symptoms of upper airway infection. B. Determine if the client is using an inhaler before exercising. C. Teach client to use pursed lip breathing when episodes occur. D. Review the client's routine asthma management prescriptions

Correct Answer is D

Explanation

A. Assess client for signs and symptoms of upper airway infection:
While upper airway infections can contribute to respiratory symptoms, the client's history of asthma and the exacerbation of symptoms during exercise suggest that asthma management should be a priority.

B. Determine if the client is using an inhaler before exercising:
This is a relevant consideration, and ensuring proper pre-exercise use of bronchodilators (such as an inhaler) is an important aspect of asthma management. However, the question is broader and involves a review of the client's overall asthma management.

C. Teach client to use pursed lip breathing when episodes occur:
Pursed lip breathing is a technique that can help manage symptoms, especially during episodes of bronchoconstriction. However, the focus here is on a more comprehensive assessment and review of the client's routine asthma management.

D. Review the client's routine asthma management prescriptions:
This is the correct answer. The client's reported symptoms during exercise suggest a potential need for adjustments to the routine asthma management plan. Reviewing the client's prescriptions, including the type and timing of medications, can help ensure optimal control of symptoms, especially during physical activity.

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After falling down the basement steps, a client is brought to the emergency room. X-rays confirms that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

Correct Answer is A

Explanation

A client with a history of asthma reports having episodes of bronchoconstriction and increased mucous production while exercising. Which action should the nurse implement?

Correct Answer is D

Explanation

After falling down the basement steps, a client is brought to the emergency room. X-rays confirms that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?

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