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

Answer and Explanation

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.

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Correct Answer is B

Explanation

The nurse should use the term "postictal phase" when documenting the client's difficulty arousing and sleepiness for several hours following a generalized tonic-clonic seizure. The postictal phase is the period of time immediately following a seizure during which the client may be difficult to arouse and very sleepy.

Presence of absence seizures, presence of automatisms, and aura phase are not appropriate descriptions for the nurse to use when documenting this finding in the medical record. Absence seizures are a type of seizure characterized by brief episodes of staring and unresponsiveness. Automatisms are repetitive, unconscious movements that can occur during a seizure. The aura phase is a warning sign that can occur before a seizure.

A. "Russell's traction uses a sling under the knee to treat a fracture of the femur." B. "Russell's traction uses a cervical halter to decrease cervical muscle spasms." C. "Russell's traction uses skeletal pins to stabilize the fracture." D. "Russell's traction uses a pelvic girdle belt to decrease lower back pain."

Correct Answer is A

Explanation

The nurse should tell the newly licensed nurse that Russell's traction uses a sling under the knee to treat a fracture of the femur. Russell's traction is a type of skin traction that is used to immobilize and align a fractured femur. It involves placing a sling under the knee and applying weights to the aﬀected leg to provide continuous traction.

Russell's traction does not use a cervical halter, skeletal pins, or a pelvic girdle belt. A cervical halter is used to treat neck injuries. Skeletal pins are used in skeletal traction to stabilize fractures. A pelvic girdle belt is used to treat lower back pain.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record?

Correct Answer is B

Explanation

A nurse is reinforcing teaching about Russell's traction with a newly licensed nurse. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

A nurse is completing a neurovascular check for a client who had an open reduction internal fixation surgery. Which of the following findings should the nurse identify as possible manifestations of compartment syndrome? (Select all that apply)

A nurse in an urgent care centre is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. Which of the following interventions should the nurse take? (Select all that apply)

A nurse is contributing to the plan of care for a client to achieve the outcome of functional healing of a fracture. Which of the following nursing interventions is the highest priority to assist in meeting this outcome?

A nurse is caring for a client who is postoperative following a right total hip arthroplasty. In which of the following positions should the nurse place the client's right leg?

A nurse at a community health clinic is caring for a client who reports a headache and stiﬀ neck. Which of the following actions should the nurse perform first?

A nurse is collecting data from a client who has a score of 8 using the Glasgow Coma Scale. Which of the following findings should the nurse expect?

A nurse is collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following is an appropriate nursing intervention for the client at this time?