A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first?
Place an ice pack over the cast.
Position the casted extremity on a pillow.
Teach the client to keep the cast clean and dry.
Palpate the pulse distal to the cast.
The Correct Answer is D
A. Place an ice pack over the cast. While this can help reduce swelling and pain, it is a comfort measure, not the priority. Safety assessments must be completed first before implementing non-urgent interventions.
B. Position the casted extremity on a pillow. Elevation is important to reduce swelling, but it follows after ensuring that circulation to the extremity is intact and that there are no signs of vascular compromise.
C. Teach the client to keep the cast clean and dry. Education is essential for long-term cast care, but it is not the first action after cast application. Immediate post-procedural monitoring takes precedence.
D. Palpate the pulse distal to the cast. The nurse should first assess for adequate circulation by checking distal pulses. This helps identify early signs of complications like compartment syndrome or impaired blood flow, making it the highest priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The client is voiding at least 250 mL/hr. This amount is excessive and not typical. The expected urine output for an adult is at least 30 mL/hr, so 250 mL/hr could indicate overhydration or diuretic use, which is not expected postoperatively.
B. The client is maintaining bed rest. Early ambulation is encouraged after surgery to prevent complications like deep vein thrombosis and promote recovery. Bed rest 36 hours post-op is not expected unless medically indicated.
C. The client is tolerating clear liquids. After gastric banding, clients typically start with clear liquids and gradually progress to more solid foods. Tolerating clear liquids at 36 hours post-op is an expected and positive finding.
D. The client is consuming 1,000 calories daily. At this stage post-op, calorie intake is significantly restricted, often much lower than 1,000 calories. Intake gradually increases as the diet progresses from liquids to solids.
Correct Answer is B
Explanation
A. Social media campaign for survivors of prostate cancer. This targets individuals with a different age demographic and cancer type. Prostate cancer primarily affects older men, while testicular cancer primarily affects younger men.
B. Information booth at a community resource fair for young adults. This is the most appropriate choice, as testicular cancer most commonly affects males between the ages of 15 and 35. Reaching this age group through community events effectively targets the at-risk population.
C. Trifold pamphlets to be distributed at a health fair for older adults. Older adults are not the primary at-risk group for testicular cancer, so this setting would not effectively reach the intended population.
D. Education for clients who experience benign prostatic hypertrophy. BPH is a condition of older men and unrelated to testicular cancer. This would not be an effective or targeted intervention.
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