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.
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Related Questions
Correct Answer is B
Explanation
a. Decreased calcium level: NG tube drainage is more likely to result in hypokalemia (decreased potassium) than hypocalcemia (decreased calcium).
b. Decreased potassium level: NG tube drainage, which contains stomach contents, can lead to loss of potassium. Monitoring for hypokalemia is crucial as it can result in cardiac dysrhythmias.
c. Elevated magnesium level: NG tube drainage is not typically associated with an increase in magnesium levels.
d. Elevated sodium level: NG tube drainage may contribute to sodium loss, leading to hyponatremia, rather than hypernatremia.
Correct Answer is B
Explanation
a. “I will wait 10 min between each inhalation.”: There is no need to wait 10 minutes between
inhalations of albuterol. The usual recommendation is to wait 1-2 minutes if a second inhalation is needed.
b. “I will hold my breath at least 10 seconds after inhaling the medication.”: Holding the breath for at least 10 seconds after inhaling helps ensure that the medication reaches the lower airways and is absorbed effectively.
c. “I will tilt my head forward while inhaling the medication.”: Tilted head position is not necessary for using an inhaler; a proper inhalation technique is more critical.
d. “I will hold the inhaler with my non-dominant hand.”: The hand used to hold the inhaler is not as crucial as proper inhalation technique, but using the dominant hand may be more comfortable for most individuals.
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