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 ["200"]

Explanation

Calculation:

Total volume to be infused = 100 mL.

Convert the infusion time from minutes to hours.

Infusion time = 30 min / 60 min/hr

= 0.5 hr.

Calculate the infusion rate in milliliters per hour (mL/hr).

Infusion rate (mL/hr) = Total volume (mL) / Infusion time (hr)

= 100 mL / 0.5 hr

= 200 mL/hr.

Answer: 200 mL/hr

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

Rationale for correct choices:

Spontaneous abortion: The client is at risk of a spontaneous abortion, as evidenced by bright red vaginal bleeding, cramping, and an open cervix at 10 weeks gestation. These findings are classic for an inevitable abortion, particularly when fetal viability has not been confirmed and symptoms are active.
Cervical dilation: Cervical dilation during the first trimester, especially in conjunction with vaginal bleeding and uterine cramping, confirms that the miscarriage process is in progress. In a viable pregnancy, the cervix remains closed, so dilation is a key indicator of pregnancy loss.

Rationale for incorrect choices:

Molar pregnancy: While molar pregnancies can cause elevated hCG levels, they typically present with painless bleeding, absence of a fetus on ultrasound, and may show signs like early-onset preeclampsia or hyperemesis. The presence of pain and cervical dilation points away from a molar pregnancy.
Ectopic pregnancy: An ectopic pregnancy more often presents with sharp unilateral lower abdominal pain, low or slowly rising hCG levels, and an empty uterus on ultrasound. The findings of cervical dilation and an hCG level consistent with intrauterine pregnancy reduce the likelihood of an ectopic pregnancy.
Bright red vaginal bleeding: Although bright red bleeding suggests active hemorrhage and is concerning, it can occur in a variety of obstetric conditions. Without cervical dilation or signs of fetal compromise, it cannot alone confirm spontaneous abortion.
History of chlamydia infection: While a history of chlamydia increases the risk of ectopic pregnancy due to tubal scarring, it is not a direct indicator of current pregnancy loss. It does not outweigh the importance of current symptoms like cervical dilation in determining the client's current risk.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["200"]

Explanation

A nurse is caring for a client at the clinic. Exhibits Complete the following sentence by using the lists of options. The client is at risk for dropdown as evidenced by dropdown.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

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