the nurse is assessing a client who had a cast placed 4 hours ago what assessment finding is cause for concern

ATI RN

Multi Dimensional Care | Final Exam

1. The nurse is assessing a client who had a cast placed 4 hours ago. What assessment finding is cause for concern?

A. The nurse assesses capillary refill of 2 seconds
B. The nurse cannot insert one finger between the cast and the skin
C. The nurse finds 2+ pulses distal from the cast
D. The nurse does not observe any drainage

Correct answer: B

Rationale: Inability to insert a finger between the cast and skin indicates the cast is too tight, risking circulation problems.

2. A client is recovering from a fractured radius that occurred 7weeks ago. Which state of bone healing occurs at this time as the callus is restored and transformed into bone?

A. Stage 3
B. Stage 5
C. Stage 1
D. Stage 4

Correct answer: D

Rationale:

3. An area of erythema on the child's skin is being assessed by the nurse. The nurse presses down on the area, and the area becomes white. What time does the nurse document for this finding?

A. Non-blanching
B. Blanching
C. Redness
D. Warmth

Correct answer: B

Rationale:

4. Which nonpharmacological intervention does not help reduce edema?

A. Heat therapy
B. Passive range of motion (PROM)
C. Elevation of the extremity
D. Cold therapy

Correct answer: A

Rationale: The correct answer is A: Heat therapy. Heat therapy can vasodilate blood vessels, increasing blood flow to the area and potentially exacerbating edema. Passive range of motion (PROM), elevation of the extremity, and cold therapy are all beneficial interventions for reducing edema. PROM helps with circulation, elevation assists in reducing fluid accumulation, and cold therapy can help constrict blood vessels and decrease swelling.