Nursing Elites

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. The nurse is caring for a client who develops compartment syndrome from a severely fractured arm. The client asks how this can happen. What is the best response by the nurse?

• A. . "The fascia expands with injury, causing pressure on underlying nerves and muscles."?
• B. "An injured artery causes impaired arterial perfusion through the compartment."?
• C. "Bleeding and swelling cause increased pressure in an area that cannot expand."?
• D. . "A bone fragment has injured the nerve supply in the area."?

Correct answer: C

Rationale:

3. What is a negative effect of immobility on the cardiovascular system?

• A. Increased high density lipoprotein
• B. Increased circulation
• C. Increased pumping action of the heart
• D. Venous stasis

Correct answer: D

Rationale: Venous stasis is a negative effect of immobility on the cardiovascular system as it can lead to blood clots.

4. A client has suffered from a femur fracture. What is the nurse's priority assessment?

• A. Pain
• B. Medication history
• C. Pedal pulses
• D. Socio-economic status

Correct answer: C

Rationale:

5. What intervention by the nurse would be the best to prevent deep vein thrombosis after a fracture of the hip?

• A. Encouraging bedrest
• B. Applying antiembolism stockings
• C. Tell the client to take anticoagulants
• D. Teaching about smoking cessation

Correct answer: B

Rationale: The best intervention to prevent deep vein thrombosis (DVT) after a fracture of the hip is to apply antiembolism stockings. These stockings help promote circulation and prevent blood clots from forming in the legs due to immobility. Encouraging bedrest is not recommended as it can increase the risk of DVT. While anticoagulants are used in some cases, the primary prevention method is mechanical prophylaxis like antiembolism stockings. Teaching about smoking cessation is important for overall health but is not directly related to preventing DVT in this scenario.

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