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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Begin continuous observation for transient episodes of neurologic dysfunction:
While continuous observation is important, the priority is to notify the stroke team for immediate assessment and management.
B. Place an indwelling urinary catheter and measure strict intake and output:
Monitoring intake and output is an important aspect of nursing care, but it is not the immediate priority when the client is presenting with signs and symptoms suggestive of a stroke.
C. Notify the stroke team to assist with acute assessment and management.
The client's symptoms, including an uneven smile with facial droop to the right side, weaker hand grasp strength on the right, and sudden, severe headache, are indicative of potential stroke symptoms. Quick notification of the stroke team is crucial to facilitate a rapid and comprehensive assessment. Time is a critical factor in the management of stroke, and prompt intervention can improve outcomes.
D. Raise the head of the bed to 30 degrees keeping head and neck in neutral alignment:
While positioning is important for maintaining physiological stability, it is not the immediate priority in the context of a potential stroke. Notifying the stroke team for rapid assessment and intervention takes precedence.
Correct Answer is B
Explanation
A. Administer intravenous fluid bolus as prescribed by the healthcare provider.
While hydration is important, the vital signs provided (elevated heart rate and respiratory rate) are more indicative of potential respiratory distress. Administering fluids may be indicated in certain situations, but it may not address the immediate concern of compromised oxygenation.
B. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter.
This is the correct choice. The client's elevated heart rate and respiratory rate suggest the need for improved oxygenation. Applying oxygen at a high flow rate via a non-rebreather mask is an immediate intervention to address potential respiratory compromise. Monitoring the pulse oximeter provides real-time feedback on oxygen saturation.
C. Medicate for pain and monitor vital signs according to protocol.
Pain management is an important aspect of post-operative care, but the immediate concern in this scenario is the potential for respiratory distress. Administering pain medication alone may not address the primary issue.
D. Encourage the client to splint the incision with a pillow to cough and deep breathe.
While encouraging the client to cough and deep breathe is important for post-thoracotomy care, the elevated vital signs suggest a need for more immediate intervention to ensure adequate oxygenation. Applying oxygen and monitoring the pulse oximeter take precedence.
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