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 C
Explanation
Rationale:
A. "Manually expressing my milk will decrease my milk supply": Milk supply is maintained by frequent emptying of the breast. Manual expression, like breastfeeding or pumping, actually stimulates continued milk production through the supply-and-demand mechanism.
B. "After 5 to 10 minutes when the breasts emptied, my baby should be removed from the breast”: Infants should not be removed from the breast based on time alone. Breastfeeding duration varies, and babies should be allowed to nurse until they release the breast or show signs of fullness.
C. "The more my baby is at the breast sucking, the more milk I will produce”: Milk production is driven by infant demand. Frequent suckling stimulates prolactin release, encouraging ongoing milk synthesis and maintaining an adequate supply.
D. "My baby should always start on the same breast when feeding”: Breastfeeding should be alternated between breasts to promote equal milk production and prevent engorgement. Starting on the same breast consistently may lead to uneven milk supply.
Correct Answer is C
Explanation
Rationale:
A. Tomato allergy: A tomato allergy is not relevant to the ingredients used in total parenteral nutrition (TPN) with fat emulsion. Tomatoes are not a component of lipid emulsions, so this does not present a concern in this context.
B. Citrus allergy: Citrus fruits are also not involved in the formulation of fat emulsions or TPN components. Therefore, a citrus allergy would not require special precautions related to the prescribed therapy.
C. Egg allergy: Lipid emulsions used in TPN often contain egg phospholipids as an emulsifying agent. Clients with an egg allergy may experience a hypersensitivity reaction, making this a critical finding that must be reported to the provider immediately.
D. Wheat allergy: Wheat is not a component of standard TPN or fat emulsions. While wheat allergies are significant for dietary intake, they do not pose a known risk with parenteral nutrition administration.
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