The nurse performing a neurovascular check on a limb in traction would report and document which finding(s) as indicative of altered circulation? (Select all that apply.)
a. Pulse is equal to uncasted limb.
b. Patient is aware of touch and warm and cold application.
c. Limb is cool to the touch.
d. Capillary refill is 5 seconds.
e. Distal limb can flex and extend.
ANS: C, D
The limb should be warm, and capillary refill should be less than 3 seconds.
You might also like to view...
A patient refuses to take his blood pressure medication because "I feel totally fine and don't need it." What action by the nurse is best?
a. Assess the patient's time orientation. b. Document the patient's non-compliance. c. Educate the patient about the medication. d. Warn the patient about possible complications.
The patient shows the necessary defining characteristics, and the nurse has diagnosed Decisional Conflict related to unclear personal values and beliefs. What essential action should the nurse take to help ensure the accuracy of this diagnosis?
1) Ask a more experienced nurse to confirm it. 2) Have a social worker interview the patient. 3) Ask the patient to confirm the diagnosis. 4) Read about Decisional Conflict in the NANDA handbook.
Illicit use of which of the following substances is associated with sudden cardiac death?
A) Heroin B) Angel dust C) Marijuana D) Cocaine
The nurse is taking a history on a patient with probable gynecologic cancer. Which clinical manifestation is a sign of metastasis?
a. Watery vaginal discharge b. Constipation c. Dyspareunia d. Dysuria