While collecting data from a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to the touch. Which of the following findings should the nurse identify as a complication to the client's condition?
Uneven cast drying
Infection
Pressure from the cast
Poor circulation
The Correct Answer is B
The nurse should identify infection as a complication to the client's condition. A warm area on the cast could indicate the presence of an underlying infection. The warmth could be due to an increase in blood flow to the area as the body tries to fight off the infection.
Uneven cast drying, pressure from the cast, and poor circulation are not complications that would cause a warm area on the cast. Uneven cast drying could cause discomfort but would not result in warmth. Pressure from the cast could cause skin breakdown but would not result in warmth. Poor circulation could cause coolness or pallor but would not result in warmth.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should place the client's right leg in abduction following a right total hip arthroplasty. Abduction means moving the leg away from the midline of the body. This position helps to prevent hip dislocation by keeping the hip joint in proper alignment.
Internal rotation, adduction, and external rotation are not appropriate positions for the client's right leg following a right total hip arthroplasty. Internal rotation means turning the leg inward towards the midline of the body. Adduction means moving the leg towards the midline of the body. External rotation means turning the leg outward away from the midline of the body. These positions can increase the risk of hip dislocation.
Correct Answer is D
Explanation
An appropriate conclusion based on this data is that the client opens his eyes when spoken to. A GCS score of 3 for eye opening indicates that the client opens his eyes in response to voice.
The client is not unconscious, as a GCS score of 3 for eye opening indicates that the client is able to open his eyes in response to voice. The client is not unable to make vocal sound, as a GCS score of 5 for best verbal response indicates that the client is able to make vocal sounds. The client may or may not be able to follow simple motor commands, as a GCS score of 5 for best motor response indicates that the client is able to localize pain.
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