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 B

Explanation

A. Recent travel: Assessing recent travel history is relevant in understanding potential exposure to certain infections or dietary habits specific to certain regions. However, for a client admitted with renal stones, the immediate focus is on understanding factors related to their condition. While travel history might be a part of the overall assessment, it is not the priority question in this context.

B. Typical diet and fluid intake history: This is the priority question. Understanding the client's typical diet, including the types of foods they consume and their fluid intake habits, is crucial. Certain dietary factors, such as high intake of oxalate-rich foods or insufficient fluid intake, can contribute to the formation of renal stones. Gathering this information helps healthcare providers identify potential dietary factors that might have led to the stones, allowing for tailored dietary recommendations and prevention strategies.

C. Vaccination records: Vaccination records are essential for preventive healthcare, but they are not directly related to the assessment of a client admitted with renal stones. While ensuring clients are up-to-date with vaccinations is important, it is not the immediate concern in the context of renal stones.

D. Last bowel movement: Bowel movements are relevant to overall health and can provide information about gastrointestinal function. However, in the specific context of assessing a client admitted with renal stones, understanding the client's bowel movements is not the primary concern. The focus should be on factors directly related to renal stones, such as diet and fluid intake history, which can inform immediate interventions and prevention strategies.

Correct Answer is ["200"]

Explanation

To calculate the rate at which the nurse should program the pump in milliliters per hour, you can use the following formula:

Rate (mL/hour) = Volume (mL) / Time (hours)

In this case, the volume is 1,000 mL (1 liter), and the time is 5 hours. Plugging these values into the formula:

Rate (mL/hour) = 1,000 mL / 5 hours = 200 mL/hour

So, the nurse should program the pump to administer the normal saline at a rate of 200 milliliters per hour.

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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

The nurse is assessing a client admitted with renal stones. During the admission assessment, what is the priority questions to ask?

Correct Answer is B

Explanation

A nurse is to administer one 1L bag of normal saline to a client over 5 hours. At what rate should the nurse program the pump in milliliters per hour? (Round to the whole number. Assume no interruptions.)

Correct Answer is ["200"]

Explanation

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