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    Ati rn adult medical surgical 2023 proctored exam

    A nurse is evaluating a client who has impaired mobility after receiving casting on their legs bilaterally. Which of the following findings requires Intervention by the nurse?

    Explanation & Rationale

    A. Oral temperature 37.8° C (100.0° F): A mild fever (37.8° C) could be a normal response to trauma or stress, especially following casting. It does not necessarily indicate an urgent issue, but it should be monitored, particularly if it increases or persists. B. Client can wiggle their toes: The ability to move the toes is a positive sign that the neurovascular function of the extremities is intact. This is reassuring and indicates that circulation and nerve function are being maintained. C. Feet warm to the touch: Warm feet suggest that there is adequate blood circulation to the extremities. This is a positive finding and does not require intervention unless other signs of complications arise. D. Pedal pulses +1: A +1 pulse indicates weak pulses, which is concerning after casting. It may be a sign of reduced circulation, and the nurse should assess for further complications such as compartment syndrome, which can result in inadequate blood flow and tissue damage.

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