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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Having the client lie prone several times each day is an appropriate nursing intervention for a client who is 2 days postoperative following an above-the-knee amputation. Lying prone can help prevent hip ﬂexion contractures, which can occur after an above-the-knee amputation².

a. Elevating the foot of the bed is not an appropriate intervention for a client who is 2 days postoperative following an above-the-knee amputation.

b. Encouraging sitting up as much as possible is not an appropriate intervention for a client who is 2 days postoperative following an above-the-knee amputation.

c. Elevating the stump on a pillow is not an appropriate intervention for a client who is 2 days postoperative following an above-the-knee amputation.

A. Taking too much prescribed medication B. Developing a respiratory infection C. Insufficient sleep D. Insufficient exercise

Correct Answer is B

Explanation

The nurse should identify that developing a respiratory infection can cause a myasthenic crisis in a client who has myasthenia gravis. A myasthenic crisis is a sudden worsening of myasthenia gravis symptoms, which can include difficulty breathing and swallowing. Respiratory infections can exacerbate these symptoms and trigger a myasthenic crisis.

Taking too much-prescribed medication, insufficient exercise, and insufficient sleep are not factors that can cause a myasthenic crisis. Taking too much-prescribed medication can cause side eﬀects but would not directly cause a myasthenic crisis. Insufficient exercise and insufficient sleep can worsen overall health but would not directly cause a myasthenic crisis.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following is an appropriate nursing intervention for the client at this time?

Correct Answer is D

Explanation

A nurse in the emergency department is assisting with the care of a client who has myasthenia gravis and is in crisis. The nurse should identify that which of the following factors can cause a myasthenic crisis?

Correct Answer is B

Explanation

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