What four further assessments of the leg injury are needed?
Assess range of motion.
Ask Mike to stand to assess if he can bear weight.
Assess skin color of the lower leg.
Assess paresthesia.
Assess pain.
Assess pulses of the lower leg.
Correct Answer : C,D,E,F
Choice A rationale
Assessing the range of motion of a severely injured leg is not appropriate during initial evaluation. Movement can worsen the injury or disrupt stabilizing measures such as splints or dressings.
Choice B rationale
Asking the patient to stand or bear weight risks further injury and is contraindicated in cases of visible deformity or massive bleeding.
Choice C rationale
Evaluating skin color helps identify potential ischemia, vascular compromise, or inadequate perfusion. Pallor or cyanosis can indicate significant circulation issues needing urgent care.
Choice D rationale
Paresthesia (tingling or numbness) reflects nerve function and can reveal nerve damage or compromised blood flow, necessitating thorough evaluation.
Choice E rationale
Pain assessment is crucial for identifying the severity of injury and potential complications such as compartment syndrome. Pain disproportionate to the injury suggests complications.
Choice F rationale
Palpating pulses assesses blood flow, ensuring the presence of distal perfusion. Absent or weak pulses require urgent vascular intervention to prevent tissue necrosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Contact isolation prevents the transmission of Clostridium difficile spores, a significant source of nosocomial infections. Private rooms reduce cross-contamination risks.
Choice B rationale
Antidiarrheal use is contraindicated in Clostridium difficile infection as it may worsen colitis by retaining toxins. Prompt stool elimination is vital.
Choice C rationale
Antibiotics are used to treat Clostridium difficile but educating the patient about antibiotic cessation is inappropriate as their use is essential for infection control.
Choice D rationale
Stool softeners are unnecessary since diarrhea is already present, and further softening may exacerbate fluid and electrolyte loss.
Correct Answer is B
Explanation
Choice A rationale
Staying with the patient and rechecking blood glucose delays immediate corrective action required for severe hypoglycemia (40 mg/dL). While safety is important, prompt treatment with glucose is the priority to prevent further complications.
Choice B rationale
Following the hypoglycemia protocol ensures immediate glucose administration, either orally, intravenously, or intramuscularly, to stabilize the patient. This is critical as glucose levels below 40 mg/dL require urgent intervention to prevent neuronal damage or coma.
Choice C rationale
Monitoring and rechecking glucose after treating is essential but not sufficient as the first action. Hypoglycemia this severe needs immediate treatment before monitoring, ensuring prompt glucose replacement to prevent worsening symptoms.
Choice D rationale
Notifying the physician without treating the hypoglycemia risks unnecessary delays. Immediate action, such as administering glucose per protocol, is vital in this emergency scenario for patient safety.
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