A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first?

Palpate the pulse distal to the cast.

Position the casted extremity on a pillow.

Place an ice pack over the cast.

Teach the client to keep the cast clean and dry.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Palpate the pulse distal to the cast: Assessing neurovascular status is the priority immediately after cast application. Palpating the distal pulse helps determine adequate circulation and can detect complications like compartment syndrome early, which can lead to permanent damage if untreated.

B. Position the casted extremity on a pillow: Elevating the extremity helps reduce swelling and pain, but it is a secondary action. Ensuring perfusion through a pulse check takes precedence before supportive comfort measures are initiated.

C. Place an ice pack over the cast: Cold therapy can help minimize swelling and pain in the initial hours after casting, but it should only be done after confirming that circulation is intact. Ice packs should also be used carefully to prevent moisture from damaging the cast.

D. Teach the client to keep the cast clean and dry: Education is important for long-term cast care, but it is not the immediate priority after application. Early assessment for circulation, sensation, and movement must occur first to ensure the cast has not compromised perfusion.

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Correct Answer is C

Explanation

Rationale:

A. A client who is bedridden and wears a hearing aid: This client requires significant assistance to evacuate and is not the highest priority for immediate evacuation. Clients needing more help are usually evacuated after those who can walk.

B. A client who has a fracture and is in balance suspension traction: This client is non-ambulatory and immobilized, requiring complex movement. Evacuation would be delayed until ambulatory clients are cleared.

C. A client who is ambulatory and receiving oxygen: Ambulatory clients are evacuated first because they can move with minimal assistance. Although on oxygen, this client can quickly exit the danger zone, reducing congestion and risk.

D. A client who uses a wheelchair and is confused: This client needs assistance due to confusion and limited mobility. They are evacuated after ambulatory clients to allow for orderly and efficient evacuation.

A. Use an incentive spirometer every 4 hours B. Remain on bed rest for 24 hours following the procedure C. Place a pillow under your knees while in bed D. Participate in range of motion exercises.

Correct Answer is D

Explanation

Rationale:

A. Use an incentive spirometer every 4 hours: Incentive spirometry is primarily used to promote lung expansion and prevent atelectasis postoperatively. While important, it is aimed at respiratory function, not directly at promoting circulation.

B. Remain on bed rest for 24 hours following the procedure: Prolonged bed rest can lead to venous stasis and increase the risk of thromboembolic events. Early ambulation or movement is encouraged to improve circulation and prevent complications like deep vein thrombosis (DVT).

C. Place a pillow under your knees while in bed: Placing a pillow under the knees can cause venous stasis by compressing the popliteal vessels and should be avoided. It may also contribute to joint stiffness and increase the risk of DVT.

D. Participate in range of motion exercises: Range of motion exercises encourage venous return and stimulate blood flow in the extremities. This helps prevent postoperative complications such as DVT and promotes overall circulatory health.

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A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first?

Nursing Test Bank

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