Nokea
The nurse, caring for a client who has been placed in Buck's extension traction while awaiting surgical repair of a fractured femur, should perform a complete neurovascular assessment of the affected extremity that include which interventions? Select all that apply.
- A. Vital signs
- B. Bilateral lung sounds
- C. Pulse in the affected extremity
- D. Level of pain in the affected leg
- E. Skin color of the affected extremity
- F. Capillary refill of the affected toes
Correct Answer: C,D,E,F
Rationale: A complete neurovascular assessment of an extremity includes color, sensation, movement, capillary refill, and pulse of the affected extremity. Options 1 and 2 are not related to neurovascular assessment.
You may also like to solve these questions
The nurse is caring for a client who is receiving blood transfusion therapy. Which clinical manifestations should alert the nurse to a hemolytic transfusion reaction? Select all that apply.
- A. Headache
- B. Tachycardia
- C. Hypertension
- D. Apprehension
- E. Distended neck veins
- F. A sense of impending doom
Correct Answer: A,B,D,F
Rationale: Hemolytic transfusion reactions are caused by blood type or Rh incompatibility. When blood containing antigens different from the client's own antigens is infused, antigen-antibody complexes are formed in the client's blood. These complexes destroy the transfused cells and start inflammatory responses in the client's blood vessel walls and organs. The reaction may include fever and chills or may be life-threatening with disseminated intravascular coagulation and circulatory collapse. Other manifestations include headache, tachycardia, apprehension, a sense of impending doom, chest pain, low back pain, tachypnea, hypotension, and hemoglobinuria. The onset may be immediate or may not occur until subsequent units have been transfused. Distended neck veins are characteristics of circulatory overload.
A client is admitted to the cardiac intensive care unit after coronary artery bypass graft (CABG) surgery. The nurse notes that in the first hour after admission, the mediastinal chest tube drainage was 75 mL. During the second hour, the drainage has dropped to 5 mL. The nurse interprets this data and implements which intervention?
- A. Identifies that the tube is draining normally
- B. Assesses the tube to locate a possible occlusion
- C. Auscultates the lungs for appropriate bilateral expansion
- D. Assists the client with frequent coughing and deep breathing
Correct Answer: B
Rationale: After CABG surgery, chest tube drainage should not exceed 100 to 150 mL per hour during the first 2 hours postoperatively, and approximately 500 mL of drainage is expected in the first 24 hours after CABG surgery. The sudden drop in drainage between the first and second hour indicates that the tube is possibly occluded and requires further assessment by the nurse. Options 1, 3, and 4 are incorrect interventions.
The nurse is assigned to care for an infant on the first postoperative day after a surgical repair of a cleft lip. Which nursing intervention is appropriate when caring for this child's surgical incision?
- A. Rinsing the incision with sterile water after feeding
- B. Cleaning the incision only when serous exudate forms
- C. Rubbing the incision gently with a sterile cotton-tipped swab
- D. Replacing the Logan bar carefully after cleaning the incision
Correct Answer: A
Rationale: The incision should be rinsed with sterile water after every feeding. Rubbing alters the integrity of the suture line. Rather, the incision should be patted or dabbed. The purpose of the Logan bar is to maintain the integrity of the suture line. Removing the Logan bar on the first postoperative day would increase tension on the surgical incision.
A client with an extremity burn injury has undergone a fasciotomy. The nurse prepares to provide which type of wound care to the fasciotomy site?
- A. Dry sterile dressings
- B. Hydrocolloid dressings
- C. Wet, sterile saline dressings
- D. One-half-strength povidone-iodine dressings
Correct Answer: C
Rationale: A fasciotomy is an incision made extending through the subcutaneous tissue and fascia. The fasciotomy site is not sutured but is left open to relieve pressure and edema. The site is covered with wet sterile saline dressings. After 3 to 5 days, when perfusion is adequate and edema subsides, the wound is debrided and closed. A hydrocolloid dressing is not indicated for use with clean, open incisions. The incision is clean, not dirty, so there should be no reason to require povidone-iodine. Additionally, povidone-iodine can be irritating to normal tissues.
An anxious client enters the emergency department seeking treatment for a laceration of the finger. The client's vital signs are pulse 106 beats per minute, blood pressure (BP) 158/88 mm Hg, and respirations 28 breaths per minute. After cleansing the injury and reassuring the client, the nurse rechecks the vital signs and notes a pulse of 82 beats per minute, BP 130/80 mm Hg, and respirations 20 breaths per minute. Which factor likely accounts for the change in vital signs?
- A. Cooling effects of the cleansing agent
- B. Client's adaptation to the air conditioning
- C. Early clinical indicators of cardiogenic shock
- D. Decline in sympathetic nervous system discharge
Correct Answer: D
Rationale: Physical or emotional stress triggers sympathetic nervous system stimulation. Increased epinephrine and norepinephrine cause tachycardia, high blood pressure, and tachypnea. Stress reduction then returns these parameters to baseline as the sympathetic discharge falls.