A client who has a lower-leg cast reports skin irritation around the upper edge of the cast. Which of the following actions should the nurse take?
Suggest that the client use a blunt object such as a comb to relieve the itch.
Petal the edges of the cast.
Tell the client to apply lotion to the irritated skin.
Bivalve the cast.
The Correct Answer is B
If a client reports skin irritation around the upper edge of a lower-leg cast, the nurse should petal the edges of the cast. This involves applying adhesive strips or moleskin around the edges of the cast to smooth them out and prevent them from rubbing against the skin.
a. Suggesting that the client use a blunt object such as a comb to relieve the itch is not recommended as it can cause further irritation or damage to the skin.
c. Telling the client to apply lotion to the irritated skin is not recommended as it can cause further irritation or damage to the skin and may also damage the cast.
d. Bivalving the cast is not necessary for skin irritation around the upper edge of the cast. Bivalving involves cutting the cast in half to relieve pressure and is typically only done in cases of severe swelling or compartment syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
An appropriate action to prevent hip dislocation in a client who is postoperative following a total hip arthroplasty is to place a wedge pillow between the legs. This helps to maintain proper alignment and prevent the legs from crossing or adducting, which can cause hip dislocation.
Placing a trochanter roll against the thigh, placing a sandbag on the lateral calf, and placing a footboard on the bed are not appropriate actions to prevent hip dislocation in this situation. A trochanter roll is used to prevent the external rotation of the hip. A sandbag to the lateral calf can help prevent foot drop. A footboard can help prevent plantar flexion contractures.
Correct Answer is C
Explanation
The priority intervention for the nurse to implement for a newly-admitted client who has acute osteomyelitis is antibiotic therapy. Osteomyelitis is an inflammatory condition of bone secondary to an infectious process¹. Antibiotics are the primary treatment option and should be tailored based on culture results and individual patient factors.
a. Optimal nutrition and hydration is important but not the priority intervention.
b. Surgical debridement of necrotic tissue may be necessary but is not the priority intervention.
d. Antipyretic therapy may be necessary but is not the priority intervention.
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