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. Gelatin: Gelatin allergies are more relevant when assessing for risk with certain vaccines like MMR or varicella, which may contain gelatin as a stabilizer. It is not a primary concern with most influenza vaccines.

B. Shellfish: Shellfish allergies are associated with reactions to iodine-based contrast, not vaccines. They do not impact the safety of receiving the influenza vaccine.

C. Egg: Many influenza vaccines are manufactured using egg-based processes, which can leave residual egg protein. Although most clients with egg allergies can now safely receive the vaccine, this allergy is still important to assess before administration.

D. Milk: Milk allergies are not linked to influenza vaccines and do not affect vaccine safety. There is no milk protein used in the manufacturing of flu vaccines.

A. Weigh the client before and after the procedure. B. Administer a low-volume hypertonic enema the night before the procedure. C. Place the client in a side-lying position for the procedure. D. Ensure the client has a full bladder just prior to the procedure.

Correct Answer is A

Explanation

Rationale:

A. Weigh the client before and after the procedure: Weighing the client helps to assess the volume of fluid removed and its immediate impact on the client’s body weight. This also assists in evaluating the effectiveness of the procedure and monitoring for fluid imbalances or complications.

B. Administer a low-volume hypertonic enema the night before the procedure: Enemas are not indicated for paracentesis, which involves the peritoneal cavity, not the bowel. Preparing the bowel is not necessary for this procedure and does not influence its safety or effectiveness.

C. Place the client in a side-lying position for the procedure: Paracentesis is typically performed with the client in a semi- to high-Fowler’s position. This position causes ascitic fluid to collect in the lower abdomen, making it more accessible and reducing the risk of organ puncture.

D. Ensure the client has a full bladder just prior to the procedure: The bladder should be emptied before paracentesis to reduce the risk of accidental puncture. A full bladder increases the chance of bladder injury during the needle insertion into the peritoneal cavity.

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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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