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 A
Explanation
A. Drink at least 8 cups (1920 mL) of water per day:
This is the correct answer. Adequate hydration is important in the management of gout because it helps to flush out uric acid and prevent the formation of urate crystals. Increasing fluid intake, especially water, is a key component of gout management.
B. Eat high protein foods to achieve ideal body weight:
While maintaining a healthy weight is important in managing gout, the emphasis should be on a balanced diet that includes adequate hydration and avoidance of foods high in purines, which can contribute to increased uric acid levels.
C. Encourage active range of motion to limit stiffness:
Active range of motion exercises can be beneficial for joint health, but the primary emphasis in gout management is on dietary and pharmacological interventions.
D. Use an electric heating pad when pain is at its worse:
Applying heat may provide some relief, but it is not the primary intervention for gout. Cold compresses or ice may be more appropriate for acute gout attacks.
Correct Answer is A
Explanation
A. Platelet count 40,000 x10/μL (40.000 x109/L):
This is the correct answer. A platelet count of 40,000 x10/μL is significantly below the normal range (usually around 150,000 to 450,000/μL). Low platelet count (thrombocytopenia) can increase the risk of bleeding during and after a surgical procedure. The healthcare provider should be alerted to assess the risk and determine the appropriate management.
B. White blood cells 9,000/μL (9x109/L):
The white blood cell count is within the normal range, and it is not a significant concern for a vertebroplasty procedure.
C. Hematocrit 38% (0.38):
The hematocrit level is within the normal range and is not a significant concern for a vertebroplasty procedure.
D. Hemoglobin 12 g/dL (120 g/L):
The hemoglobin level is within the normal range and is not a significant concern for a vertebroplasty procedure.
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