A nurse is assessing a client who has a cast in place for a fractured tibia. Which of the following actions should the nurse take first?

Performing range of motion

Managing pain

Checking capillary refill

Discussing cast care

Answer and Explanation

The Correct Answer is C

A. Performing range of motion:
Explanation: Range of motion exercises are important for preventing joint stiffness and muscle atrophy, especially in clients with casts. However, this is not the first priority. Ensuring adequate circulation and perfusion is crucial before initiating any exercises or movements, as compromised circulation could lead to serious complications.

B. Managing pain:
Explanation: Pain management is important for the client's comfort, but it is not the first priority in this context. Assessing circulation and ensuring there are no signs of compromised perfusion takes precedence. Pain management can follow once circulation has been confirmed as adequate.

C. Checking capillary refill:
Explanation: Checking capillary refill is the first priority when assessing a client with a cast. Capillary refill assesses peripheral circulation by pressing on the nail bed and observing how quickly color returns. Delayed capillary refill could indicate compromised blood flow, which is a serious concern and requires immediate intervention.

D. Discussing cast care:
Explanation: Educating the client about cast care is important, but it is not the first priority. Ensuring proper circulation and ruling out any signs of impaired perfusion must be addressed before discussing cast care instructions.

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Correct Answer is C

Explanation

A. Avoiding the use of ice packs to treat muscle pain - While ice packs can cause skin damage in older adults with thinning skin, it is not the most appropriate response to the question. Protecting against shearing injuries is a more direct and specific concern related to thinning skin.

B. Protecting older adults against excessive sweat accumulation - Excessive sweat accumulation can lead to skin irritation, but this option does not directly address the issue of thinning skin as the primary concern in the question.

C. By protecting older adults against shearing injuries
Thinning skin in older adults makes them more vulnerable to skin injuries, especially shearing injuries. Shearing occurs when the skin is pulled in one direction while the underlying bone and tissues are pulled in the opposite direction. This can lead to skin tears and other wounds, which can be painful and slow to heal in older adults. Nurses should take special precautions to prevent shearing injuries, such as using lift sheets or sliding devices when moving patients, and ensuring that patients are repositioned frequently to reduce friction and shearing forces.

D. Avoiding the use of lotion on older adults' skin - Proper moisturization of the skin is important, especially in older adults, to prevent dryness and skin breakdown. Avoiding lotion is not a recommended practice; instead, choosing appropriate, non-irritating lotions can help maintain skin integrity.

A. Provide the client with antipyretic therapy. B. Administer antibiotics to the client. C. Teach relaxation breathing to reduce the client's pain. D. Increase the client's protein intake.

Correct Answer is B

Explanation

A. Provide the client with antipyretic therapy. - Antipyretic therapy can help reduce fever, but addressing the underlying infection with antibiotics is crucial.

B. Administer antibiotics to the client. -The priority intervention for a client with acute osteomyelitis is to administer antibiotics promptly. Osteomyelitis is a severe bacterial infection of the bone, which requires aggressive antibiotic therapy to eradicate the infection. Delaying antibiotic treatment can lead to further complications and the spread of the infection.

C. Teach relaxation breathing to reduce the client's pain. - Pain management is important, but in the case of acute osteomyelitis, the priority is to eliminate the infection through antibiotics.

D. Increase the client's protein intake. - Adequate nutrition, including protein, is important for overall healing and immune function, but it is not the priority when dealing with an acute infection that requires immediate antibiotic treatment.

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A nurse is assessing a client who has a cast in place for a fractured tibia. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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