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. Canned black beans: While black beans are nutritious, the canned variety often contains high sodium content, which can contribute to elevated blood pressure. Unless rinsed or labeled low-sodium, they are not ideal for a hypertension diet.
B. Cheese: Many cheeses are high in sodium and saturated fats, which can worsen hypertension. Regular consumption should be limited or replaced with low-sodium, low-fat alternatives.
C. Fish: Fish, especially fatty varieties like salmon and mackerel, are rich in omega-3 fatty acids, which support cardiovascular health and help lower blood pressure. They are a heart-healthy protein choice for individuals with hypertension.
D. Red meat: Red meat is often high in saturated fat and sodium, particularly when processed. Frequent intake is associated with increased blood pressure and cardiovascular risks, making it less suitable for a hypertension-friendly diet.
Correct Answer is C
Explanation
Rationale:
A. Hypertension: Dehydration in infants typically causes hypotension, not hypertension, due to reduced circulating volume and poor perfusion as fluid loss progresses.
B. Decreased temperature: While temperature may fluctuate in dehydration, fever is more common due to infection-related fluid loss. A decreased temperature is not a consistent sign.
C. Oliguria: Decreased urine output is a key indicator of dehydration in infants. The kidneys conserve water during hypovolemia, resulting in oliguria (less than 1 mL/kg/hr).
D. Bulging anterior fontanel: A bulging fontanel usually indicates increased intracranial pressure, not dehydration. Dehydration typically causes a sunken fontanel in infants.
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