Patient data
The nurse considers the brief interaction with the client and the triage report.
Which finding(s) should the nurse investigate further? Select all that apply.
Left arm that is cool to touch
Decreased range of motion
Swelling at the site of injury
Intense pain reported by client
Oxygen saturation 95% on room air
Blood pressure of 136/90 mm Hg
Nausea and fatigue reported by client
Bone misalignment
Correct Answer : A,B,D,G,H
A. Left arm that is cool to touch: A cool extremity can indicate impaired circulation, which is a priority concern after trauma. It may suggest compromised perfusion or neurovascular compromise, requiring immediate further investigation.
B. Decreased range of motion: The inability to move the left arm signals possible fracture, dislocation, or neurovascular impairment. Limited mobility after trauma should always be investigated to determine the extent of musculoskeletal injury.
C. Swelling at the site of injury: Swelling is expected following trauma and does not necessarily indicate a complication. While it should be monitored, it is not as urgent to investigate further compared with circulation or alignment changes.
D. Intense pain reported by client: Severe, constant pain out of proportion to the injury raises concern for complications such as compartment syndrome, fracture, or vascular compromise. This finding requires prompt further assessment and intervention.
E. Oxygen saturation 95% on room air: Although slightly lower than ideal, this level is still acceptable in an older adult and not immediately alarming. It does not require urgent further investigation compared to other more critical findings.
F. Blood pressure of 136/90 mm Hg: This blood pressure indicates mild hypertension but is not an acute concern in the setting of trauma. It does not require urgent investigation at this point.
G. Nausea and fatigue reported by client: These symptoms may suggest a head injury, concussion, or internal response to trauma. Given the reported head impact, these findings warrant further neurological evaluation.
H. Bone misalignment: Visible misalignment strongly suggests fracture or dislocation. This finding must be investigated further to confirm the diagnosis and prevent neurovascular complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Provide a bedside commode for toileting: Minimizing physical exertion helps reduce cardiac workload in a client with heart failure. Providing a bedside commode decreases the need for frequent trips to the bathroom, conserving energy and reducing strain on the heart.
B. Assist with ambulation in the hallway: While ambulation promotes circulation and prevents complications of immobility, it increases oxygen demand and cardiac workload, which may not be safe for a client with acute heart failure.
C. Teach to sleep in a side-lying position: Side-lying may improve comfort but does not significantly impact cardiac workload or oxygen consumption compared with upright or semi-Fowler positions that promote easier breathing.
D. Encourage active range of motion exercises: Active exercises increase metabolic demand and cardiac workload. Although beneficial long-term, they should be limited during acute illness to prevent overexertion and exacerbation of heart failure.
Correct Answer is "{\"xRanges\":[24.75253686935637,42.04549690532573],\"yRanges\":[62.826215561361366,80.16865945855535]}"
Explanation
To measure blood pressure from the left thigh, the diaphragm of the stethoscope should be placed over the popliteal artery, which is located behind the knee. This placement allows you to auscultate the Korotkoff sounds accurately when measuring thigh blood pressure.

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