a client with a cast complains of numbness and tingling in the affected limb what should the nurse do first
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Nursing Elites

HESI LPN

Adult Health 2 Final Exam

1. A client with a cast complains of numbness and tingling in the affected limb. What should the nurse do first?

Correct answer: A

Rationale: The correct first action for a client with a cast experiencing numbness and tingling in the affected limb is to check for tightness of the cast. Numbness and tingling can indicate compromised circulation, and a tight cast may be causing this. Checking the cast for tightness is essential to ensure it is not impeding circulation. Elevating the limb, applying ice, or notifying the physician can be subsequent actions depending on the assessment findings after checking the cast. Elevating the limb might help improve circulation, applying ice is not indicated for numbness and tingling, and notifying the physician can be done if the issue persists after addressing the immediate concern of cast tightness.

2. A client with type 1 diabetes is experiencing symptoms of hypoglycemia. What is the nurse's priority intervention?

Correct answer: D

Rationale: The priority intervention for a client with type 1 diabetes experiencing symptoms of hypoglycemia is to give 15 grams of a fast-acting carbohydrate. In a hypoglycemic state, the priority is to quickly raise the blood glucose level. Administering glucagon intramuscularly (Choice A) is reserved for severe hypoglycemia when the client is unable to take oral carbohydrates. Providing a complex carbohydrate snack (Choice B) is beneficial after the initial treatment of hypoglycemia to prevent recurrence. Administering 50% dextrose intravenously (Choice C) is a more invasive intervention typically done in a hospital setting for severe cases.

3. A client with a history of pulmonary embolism is on anticoagulant therapy. What should the nurse monitor regularly?

Correct answer: A

Rationale: Correct! Monitoring INR is essential in clients on anticoagulant therapy to ensure the blood's clotting time is within the therapeutic range, preventing further embolic events or excessive bleeding. Monitoring blood glucose levels (Choice B), blood pressure (Choice C), and temperature (Choice D) is important for various other conditions but is not directly related to anticoagulant therapy for a client with a history of pulmonary embolism.

4. A client is admitted with Atrial Fibrillation and is administered amiodarone (Cordarone). What therapeutic response should the nurse anticipate?

Correct answer: A

Rationale: The correct answer is A: Conversion of irregular heart rate to regular heart rhythm. Amiodarone is a medication commonly used to restore and maintain normal heart rhythm in clients with atrial fibrillation. It works by slowing down the electrical signals in the heart, helping to regulate the heartbeat. Choices B, C, and D are incorrect because they do not directly relate to the therapeutic response expected from administering amiodarone in a client with atrial fibrillation. Pulse oximetry readings, peripheral pulses, capillary refill, and exercise tolerance are important assessments but are not the primary therapeutic goal of using amiodarone in this situation.

5. Prior to administering morphine sulfate (Morphine), the nurse takes the client's vital signs. Based on which finding should the nurse withhold administration of the medication until the charge nurse is notified?

Correct answer: C

Rationale: The correct answer is C because a low respiratory rate is a critical concern when administering opioids like morphine, as they can suppress breathing. A high pulse rate (choice B) and high blood pressure (choice D) are not immediate contraindications for administering morphine. A slightly elevated temperature (choice A) may not necessarily require withholding morphine.

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