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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. There is no need for the client to lie flat for an extended period after a DEXA scan. The procedure is non-invasive and does not require immobilization.
B. Emptying the bladder before the test is essential to ensure a clear and accurate scan of the pelvis and lower spine. A full bladder might obstruct the view and affect the accuracy of the results.
C. DEXA scans do not typically require the use of IV dye. It is a simple X-ray procedure that measures bone density, and no contrast material is usually needed.
D. Fasting is not necessary for a DEXA scan. The procedure does not involve ingesting or injecting any substances that require fasting.
Correct Answer is A
Explanation
A. Urine culture and sensitivity
Explanation: A urine culture and sensitivity test involves growing bacteria from a urine sample in a laboratory setting. Once the bacteria have grown, they are exposed to different antibiotics to see which one is most effective in inhibiting their growth. This helps healthcare providers identify the specific strain of bacteria causing the infection and choose the most appropriate antibiotic treatment.
B. Serum creatinine level
Explanation: Serum creatinine level is a blood test used to measure kidney function. It evaluates how well the kidneys are filtering waste from the blood. While important for assessing kidney health, it does not determine the specific bacteria causing a urinary tract infection or the appropriate antibiotic treatment.
C. Urinalysis
Explanation: Urinalysis is a broad screening test that assesses various components in the urine, such as red and white blood cells, protein, glucose, and bacteria. While it can detect signs of a urinary tract infection (such as the presence of bacteria and white blood cells), it does not identify the specific bacterial strain causing the infection or provide information about antibiotic sensitivity.
D. Kidney scan
Explanation: A kidney scan, also known as a renal scan, is a medical imaging technique used to assess the structure and function of the kidneys. It can help diagnose conditions like kidney stones, urinary obstruction, or kidney infections. However, it does not determine the strain of bacteria causing a urinary tract infection or guide antibiotic treatment.
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