ATI B Q&A LATEST GURANTEED PASS
• Extremity cool upon palpation – CORRECT o The nurse should report indicators of reduced circulation, such as pallor, cool temperature, or paresthesia of the client's extremity. These findings can indicate that the client is at risk for developing acute compartment syndrome. • Serosanguineous drainage on the dressing – INCORRECT o Serosanguineous, or blood-tinged, drainage on the dressing is an expected finding following surgery. Serosanguineous drainage is present the first few days following surgery as the wound heals. • Capillary refill of 2 seconds – INCORRECT o A capillary refill of 2 seconds is within the expected reference range and indicates the client has adequate arterial blood flow. A delay in capillary refill can indicate an earl manifestation of acute compartment syndrome. • Client report of discomfort when moving toes – INCORRECT o A report of discomfort when moving toes is an expected finding following surgery. However, a report of increased pain at the surgical site when moving can indicate an early manifestation of acute compartment syndrome.
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