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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. “I will notify my provider before taking any other medications.” - This statement reflects an understanding of the need to check for potential interactions with other medications, which is an appropriate response.

B. “I have made an appointment to see my dentist next week.” - Dental care is important, and

scheduling an appointment with the dentist is a responsible action. However, it does not indicate a misunderstanding about the medication.

C. “I will take this medication with meals.” - Taking phenytoin with meals is a correct instruction as it can help reduce gastrointestinal side effects.

D. "I'll be glad when my seizures stop so I can quit taking this medicine." - This statement

indicates a misunderstanding about the chronic nature of anti-seizure medications. The client needs further education on the importance of continuing the medication even if seizures stop.

A. “I will drink plenty of fluids after the test.” B. “I will expect my stool to be black after this procedure.” C. “I will expect a warm feeling when the dye is injected.” D. “I will maintain a clear liquid diet 24 hours before the test.”

Correct Answer is A

Explanation

a.The statement "I will drink plenty of fluids after the test" indicates the client's understanding that hydration is important after the procedure, which is also a crucial aspect of post-procedure care. This response suggests the client understands the need to stay hydrated after ingesting barium, which helps eliminate the contrast material from the body and prevents constipation.

b. “I will expect my stool to be black after this procedure.”: The statement is related to the potential side effects of barium, but it does not address the pre-test instructions.

c. “I will expect a warm feeling when the dye is injected.”: This statement may relate to the sensation during the test but does not address the pre-test instructions.

d.while fasting may be required before the test, a clear liquid diet is not typically maintained for 24 hours prior to the procedure.

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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?

Nursing Test Bank

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Correct Answer is D

Explanation

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Correct Answer is A

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