A nurse is caring for a client who had a fiberglass cast applied 30 min ago for a fractured tibia. Which of the following actions should the nurse take?

Maintain affected leg elevated on several pillows.

Instruct the client to wiggle the toes once every 4 hr.

Use a hair dryer to promote drying of the cast.

Apply heat to the client's cast to provide pain relief.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The nurse should maintain the affected leg elevated on several pillows to reduce swelling and promote venous return. Elevating the leg helps minimize edema, which can be beneficial for the healing process and overall comfort of the client.

Choice B rationale:

Instructing the client to wiggle the toes once every 4 hours is not necessary and may cause discomfort to the fractured tibia. Toe wiggling does not provide any significant benefit in this context and could potentially disrupt the healing process.

Choice C rationale:

Using a hair dryer to promote drying of the cast is not recommended. Applying heat to the fiberglass cast may alter its integrity and lead to uneven drying, potentially weakening the cast's support.

Choice D rationale:

Applying heat to the client's cast for pain relief is not advisable. Heat may also weaken the cast material and is unlikely to provide effective pain relief for a fractured tibia. Instead, the nurse should follow the prescribed pain management plan and use appropriate pain medications as ordered by the healthcare provider.

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Correct Answer is C

Explanation

Choice A rationale:
Assessing the need for oral suction every 4 hours is essential in maintaining airway patency and preventing complications associated with excessive secretions. This is an appropriate action and does not require clarification.
Choice B rationale:
Checking the ventilator settings every 12 hours is necessary to ensure that the mechanical ventilation is providing adequate support for the client's respiratory needs. This prescription is appropriate and does not need clarification.
Choice C rationale:
Keeping the head of the client's bed elevated at 30° is important in preventing aspiration and ventilator-associated pneumonia. This position helps promote optimal lung expansion and improves oxygenation in ventilated clients.
Choice D rationale:
Performing oral hygiene using an alcohol-based oral rinse is not recommended for clients receiving mechanical ventilation. Alcohol-based products can be harmful if aspirated and may disrupt the normal oral flora, leading to complications. The nurse should use a non-alcohol-based oral rinse or foam swabs instead.

A. "When taking leflunomide, expect decreased swelling within 1 week.". B. "If acute inflammation is present, apply hot packs directly to the joint for pain relief.". C. "Take calcium and vitamin D supplements along with your steroid medication.". D. "Make sure your varicella vaccine is up to date.".

Correct Answer is C

Explanation

Choice A rationale:

Leflunomide is a disease-modifying antirheumatic drug (DMARD) used for rheumatoid arthritis, but it does not typically result in decreased swelling within one week. It usually takes several weeks or even months for its full effect to be observed.

Choice B rationale:

Applying hot packs directly to the joint for pain relief is not recommended for rheumatoid arthritis, as heat can exacerbate inflammation. Cold packs or other anti-inflammatory measures are more appropriate.

Choice C rationale:

Steroid medications, such as prednisone, can lead to bone density loss and an increased risk of osteoporosis. Taking calcium and vitamin D supplements helps to mitigate this risk.

Choice D rationale:

The Varicella vaccine is not directly related to rheumatoid arthritis. It is important for immune support, but it is not specifically required for rheumatoid arthritis treatment.

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A nurse is caring for a client who had a fiberglass cast applied 30 min ago for a fractured tibia. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following actions should the nurse include in the plan of care?

Correct Answer is C

Explanation

A nurse is teaching an adult client who has been recently diagnosed with rheumatoid arthritis. Which of the following should the nurse include in the teaching?

Correct Answer is C

Explanation

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