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 {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

Rationale:

Monitor for elevated temperature: Epidural anesthesia can mask symptoms of infection such as chorioamnionitis. Monitoring temperature helps detect early signs of infection or epidural-related complications.
Assess for urinary retention: Epidural anesthesia often causes loss of bladder sensation, increasing the risk for urinary retention. Regular assessments are needed to determine when catheterization is required.
Assist the client with ambulation: After epidural anesthesia, lower limb motor function may be impaired. Ambulation is unsafe due to the risk of falls and injury; bedrest is generally advised until full motor function returns.
Inform the client to expect drowsiness: Drowsiness is not a typical side effect of epidural anesthesia; it may indicate systemic absorption or another issue. Encouraging drowsiness may mask concerning symptoms that need prompt evaluation.
Encourage the client to turn from side to side: Repositioning helps maintain optimal uteroplacental perfusion and prevents hypotension caused by vena cava compression from aortocaval syndrome.

A. 2+ deep-tendon reflexes B. Respiratory rate 10/min C. Urinary output 35 mL/hr D. 3+ pedal edema

Correct Answer is B

Explanation

Rationale:

A. 2+ deep-tendon reflexes: This is a normal reflex response and indicates that the client is not yet experiencing magnesium toxicity, which would be marked by decreased or absent reflexes. It does not require immediate intervention.

B. Respiratory rate 10/min: A respiratory rate below 12/min is a critical indicator of magnesium toxicity. Magnesium sulfate can depress the central nervous system, leading to respiratory depression, which can be life-threatening and demands immediate action.

C. Urinary output 35 mL/hr: Although slightly below the typical threshold of 30 mL/hr for safe magnesium clearance, this finding is still adequate. It should be monitored closely but is not the most urgent concern at this moment.

D. 3+ pedal edema: Pedal edema is common in preeclampsia due to fluid retention and vascular changes. While notable, it does not take priority over signs of potentially life-threatening respiratory depression.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

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