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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
a. An endometrial biopsy: An endometrial biopsy is not the preferred method for detecting cervical cancer. It is more commonly used to evaluate the endometrium.
b. CA 125: CA 125 is a tumor marker used more for ovarian cancer detection and monitoring, not cervical cancer.
c. Papanicolaou test: The Papanicolaou test, also known as a Pap smear, is the preferred method for detecting cervical cancer and precancerous changes.
d. Transvaginal ultrasound: While ultrasound may be used to evaluate gynecological conditions,
it is not the primary method for detecting cervical cancer; the Pap smear is the standard screening test.
Correct Answer is C
Explanation
A. Request an order for an antiemetic - Checking vital signs is the priority before administering any medication. Antiemetics may be considered later, but the nurse needs to assess the client's overall condition first.
B. Request a dietary consult - Assessing vital signs comes before consulting for dietary issues.
The priority is to determine the client's immediate physiological status.
C. Check the client’s vital signs - This is the correct first action as it helps to evaluate the client's cardiovascular status, especially considering the potential toxicity of digoxin in the setting of
nausea and refusal of breakfast.
D. Suggest that the client rests before eating the meal - While rest may be beneficial, assessing vital signs takes precedence to rule out any acute cardiovascular compromise.
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