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.
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Related Questions
Correct Answer is A
Explanation
A. "Purchase a gift to give to your son from your baby." This is an effective strategy to help a young child feel included and valued, easing the transition and reducing potential jealousy. It fosters a positive emotional connection between the older sibling and the newborn.
B. "Make sure you are holding your baby when your son comes to visit you in the hospital." This may unintentionally make the child feel replaced or left out. It’s better for the parent to be free to hug and reassure the older child during the initial visit.
C. "Use medical terminology when teaching your son about your new baby." Medical terms may confuse or overwhelm a 4-year-old. Simple, age-appropriate language is more effective in helping the child understand the upcoming changes.
D. "Surprise your son with a new bedroom after you bring the baby home." Sudden changes can be disorienting or upsetting for young children. Involving them in the transition process before the baby arrives helps foster a sense of control and comfort.
Correct Answer is D
Explanation
A. "Why are you eating seaweed soup?" This response is judgmental and dismissive of the client’s cultural practices. It can make the client feel misunderstood or disrespected.
B. "The hospital food is more nutritious for you." This statement is inaccurate and culturally insensitive, assuming that hospital food is superior without recognizing the nutritional and emotional value of traditional foods.
C. "Does the doctor know that you are eating that?" This implies unnecessary medical concern and may make the client feel like her personal choices require approval, which can be disempowering and disrespectful.
D. "Of course, I will heat that up for you." This response is supportive and culturally competent, respecting the client's traditions and preferences while promoting comfort and emotional well-being during the postpartum period.
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