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. "Morphine 3 mg SQ every 4 hr PRN for pain.": The abbreviation "SQ" is considered unsafe and can be misinterpreted. The Joint Commission recommends avoiding this abbreviation and writing out "subcutaneous" to ensure clarity and patient safety.

B. "Morphine 3.0 mg sub q every 4 hr PRN for pain.": Using a trailing zero (e.g., "3.0 mg") increases the risk of a dosing error if the decimal point is missed. Standard documentation practices recommend omitting trailing zeros for whole numbers.

C. "Morphine 3 mg subcutaneous every 4 hr PRN for pain.": This entry uses the full name "subcutaneous," avoids unsafe abbreviations, and omits the trailing zero, adhering to safe and standardized medication documentation guidelines.

D. "Morphine 3 mg SC q4hr PRN for pain.": Both "SC" and "q4hr" are discouraged abbreviations. "SC" can be confused with "SL" (sublingual), and "q" abbreviations can be misread. Writing terms in full reduces the risk of misinterpretation.

A. Monitor the client's vital signs every hour following the procedure. B. Review the client's platelet count level prior to the procedure. C. Inform the client that their bladder should be full before the procedure. D. Obtain the client's consent following the procedure.

Correct Answer is B

Explanation

Rationale:

A. Monitor the client's vital signs every hour following the procedure: Vital signs, especially blood pressure, should be monitored more frequently—usually every 5 to 15 minutes immediately after epidural initiation—to assess for hypotension, a common complication.

B. Review the client's platelet count level prior to the procedure: A low platelet count increases the risk of epidural hematoma during needle insertion. Reviewing coagulation status is essential to ensure it's safe to proceed with epidural placement.

C. Inform the client that their bladder should be full before the procedure: The bladder should be emptied, not full, prior to the procedure. A full bladder increases discomfort, impairs fetal descent, and may lead to urinary retention after the epidural is placed.

D. Obtain the client's consent following the procedure: Informed consent must be obtained before any invasive procedure, including epidural anesthesia. Performing the procedure without prior consent violates patient autonomy and legal standards.

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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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