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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Rationale:
A. Maintain the head of the client's bed at a 30° angle or higher: Elevating the head of the bed reduces the risk of aspiration by preventing gastric contents from entering the airway, especially during and after feeding.
B. Check gastric residuals every 4 hr: Regular residual checks help assess gastric emptying and tolerance of enteral feeding. High residuals may indicate delayed gastric motility and require intervention.
C. Check placement of the feeding tube by x-ray once daily: An x-ray is used only once to confirm initial tube placement. Daily x-rays are unnecessary unless dislodgement is suspected; routine placement verification is done via pH testing or aspiration.
D. Ensure the formula is cold before administration: Cold formula can cause cramping or discomfort. It should be at room temperature before administration to promote tolerance and reduce gastrointestinal side effects.
E. Change the feeding container and tubing every 24 hr: Changing feeding equipment every 24 hours prevents microbial contamination, especially with continuous feeding, and is consistent with infection control guidelines.
Correct Answer is A
Explanation
Rationale:
A. "Can you talk about what was happening with your partner at home?": This open-ended question encourages the partner to express emotions and provide context, which helps build trust and gather relevant information. It’s a therapeutic response that validates the partner’s experience without judgment or assumptions.
B. "Why do you think your partner's symptoms are progressing so quickly?” This question may come off as accusatory or put the partner on the defensive. "Why" questions can create a sense of blame or pressure, which is not conducive to a supportive therapeutic environment.
C. "You should make sure your partner takes the prescribed medication”: This directive may be perceived as dismissive and does not acknowledge the partner’s emotional distress. While medication adherence is important, this is not the most therapeutic or empathetic initial response.
D. "You did the right thing by bringing your partner in for treatment”: While affirming the decision is supportive, this response closes the conversation and doesn’t invite the partner to explore their concerns or emotions further, limiting therapeutic dialogue.
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