While performing a neurovascular assessment distal to a client's fracture site, the nurse determines that the client's pulse is present, regular, and full force. Which nursing action should be taken next?
Observe the color of the extremity.
Notify the healthcare provider of the assessment finding.
Discontinue elevating the client's affected extremity.
Document the neurovascular assessment as normal.
The Correct Answer is A
Choice A reason:
The correct answer is a) because observing the color of the extremity provides additional information about circulation and potential complications such as compartment syndrome.
Choice B reason: Notifying the healthcare provider is necessary if there are abnormal findings.
Choice C reason: Discontinuing elevation is not necessary unless there are signs of compromised circulation.
Choice D reason: Documenting the assessment as normal comes after completing a thorough assessment.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Providing additional oral fluids is not appropriate for SIADH and can worsen fluid retention.
Choice B reason: Measuring glucose levels is important for diabetes management but not directly related to SIADH.
Choice C reason: Offering hard candy stimulates saliva production and soothes oral mucosa, providing relief of dry mouth and the perception of thirst without adding significant fluid volume, thereby supporting strict fluid restriction in SIADH management.
Choice D reason:
Withholding a prescribed diuretic without a clear order can disrupt the therapeutic plan, exacerbate fluid retention, and falls outside the nurse’s scope; diuretic adjustments should only follow provider directions.
Correct Answer is D
Explanation
Choice A reason: Sleeping flat in a supine position may increase intraocular pressure.
Choice B reason: Observing the pupil response of the right eye is not relevant to the left eye procedure.
Choice C reason: Turning, coughing, and deep breathing are important post-surgery but not specific to cataract extraction.
Choice D reason:
The correct answer is d) because administering a stool softener helps prevent straining during bowel movements, which can increase intraocular pressure.
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