Following a fractured left tibia, which necessitated placement of long leg cast, a client is using crutches to ambulate. During an orthopedic follow-up visit, a client reports to the nurse having difficulty managing the crutches. Which assessment should the nurse perform?

Measure capillary refill time.

Palpate for dependent edema.

Determine degree of skin elasticity.

Note hand and forearm strength.

Answer and Explanation

The Correct Answer is D

A.   Capillary refill time assessment is more relevant for circulatory status and would not directly address the client's difficulty with crutch management.
B.   Palpating for dependent edema would not provide information directly related to the client's ability to use crutches.

C.   Assessing skin elasticity is not directly related to the client's ability to manage crutches.
D.   Strength in the hands and forearms is essential for proper crutch use, as these muscles bear much of the weight while ambulating with crutches.

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Correct Answer is A

Explanation

A. An ionized calcium level significantly above the reference range can lead to cardiac dysrhythmias and requires immediate attention to assess cardiac function.
B. While urine output and characteristics are important indicators of renal function, cardiac assessment takes priority due to the potential cardiac effects of hypercalcemia.
C. Assessment of deep tendon reflexes is relevant since hypercalcemia can lead to muscle weakness and diminished reflexes. However, this should be done after assessing for any cardiac dysrhythmias.
D. Comparing muscle strength bilaterally is important for assessing neurological integrity but is not the priority when hypercalcemia is suspected.

A. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity. B. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds. C. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid. D. The client with an obstruction of the large intestine who is experiencing abdominal distention.

Correct Answer is A

Explanation

A. Abdominal rigidity in a client with a bowel obstruction due to a volvulus indicates possible peritonitis, which is a medical emergency.
B. Paralytic ileus with absent bowel sounds is concerning but not immediately life- threatening.
C. A nasogastric tube draining greenish fluid is expected in small bowel obstruction.

D. Abdominal distention in large intestine obstruction is concerning but less urgent than potential peritonitis.

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Following a fractured left tibia, which necessitated placement of long leg cast, a client is using crutches to ambulate. During an orthopedic follow-up visit, a client reports to the nurse having difficulty managing the crutches. Which assessment should the nurse perform?

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Naxlex Comprehensive Predictor Exams

When assessing a client with an ionized calcium level of 17 mg/dL (4.25 mmol/L), which intervention is most important for the nurse to implement? Reference Range lonized Calcium [Adult 4.6 to 5.1 mg/dL (1.15 to 1.35 mmol/L)]

Correct Answer is A

Explanation

After receiving report on an inpatient acute care unit, which client should the nurse assess first?

Correct Answer is A

Explanation

Exhibits Click to indicate which interventions the nurse would include in the plan of care to support the expected outcomes of adequate epidural anesthesia on the mother and the fetus. Each column must have a least one but may have more than response option selected

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