A nurse is caring for a child following an open reduction and internal fixation of a fractured femur and application of a cast. The cast has a window cut in it for viewing of the incision. Which of the following actions should the nurse take first?
Turn the client so the cast will dry on all sides.
Remove the window and view the incision.
Medicate the client for pain.
Perform neurovascular checks of the affected extremity.
The Correct Answer is D
a. Turn the client so the cast will dry on all sides: While ensuring the cast is dry is important, the first priority following a surgical procedure is to assess neurovascular status to detect any
complications.
b. Remove the window and view the incision: Removing the window may compromise the cast's integrity, and the priority is to assess neurovascular status before inspecting the incision.
c. Medicate the client for pain: Pain management is important, but assessing neurovascular status is the initial priority to ensure there are no complications affecting circulation.
d. Perform neurovascular checks of the affected extremity: Neurovascular checks are the priority to detect any signs of impaired circulation or nerve function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. “You may feel some cramping during the procedure.” - This response provides an honest and accurate expectation of potential discomfort during the colonoscopy.
B. “Don’t worry, you won’t remember anything about the procedure due to the effects of the medication.” - Sedation may help with recall, but it doesn't eliminate the possibility of feeling discomfort.
C. “Most clients report more discomfort from the preparation than from the procedure itself.” - While this statement is generally true, it doesn't directly address the client's concern about pain during the colonoscopy.
D. “You shouldn’t feel any pain since the local area is anesthetized.” - Colonoscopy is typically done with conscious sedation rather than local anesthesia, and some discomfort may still be felt.
Correct Answer is C
Explanation
a. Battle's sign: Battle's sign is bruising over the mastoid process and is not a direct manifestation of increased intracranial pressure.
b. Nuchal rigidity: Nuchal rigidity (stiff neck) is associated with irritation of the meninges and is not a specific sign of increased intracranial pressure.
c. Lethargy: Lethargy or altered level of consciousness is a common manifestation of increased intracranial pressure. It can range from mild drowsiness to severe impairment of consciousness.
d. Polyuria: Polyuria is not a typical manifestation of increased intracranial pressure. Increased urine output may be associated with other conditions, such as diabetes or diuretic use.
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