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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Fever:
Fever is a classic sign of fat overload syndrome. Fat overload syndrome occurs when the body is unable to metabolize the fat in the IV fat emulsion properly, leading to fat accumulation in tissues and organs. This can result in fever, which is one of the primary manifestations. Other signs can include respiratory distress, liver dysfunction, and changes in laboratory values, such as elevated triglycerides.
Correct Answer is A
Explanation
Choice A rationale:
Properly cutting the opening on the skin barrier wafer to fit over the stoma is crucial to prevent any irritation or damage to the surrounding skin. A well-fitted wafer creates a seal around the stoma, reducing the risk of stool coming into contact with the skin, which can cause excoriation.
Choice B rationale:
Emptying the bag when it is three-fourths full of stool is unrelated to the education on colostomy care. This information was provided in the previous question () and is not relevant to colostomy care education.
Choice C rationale:
The color of the stoma should not be slightly purple. A healthy stoma should be pink or red, indicating a good blood supply. A purple or dark-colored stoma could indicate inadequate blood flow, which is a concern and requires immediate medical attention.
Choice D rationale:
Cleansing the peristomal skin with moisturizing soap and water is not the recommended approach. The nurse should use plain water or mild, non-moisturizing soap to clean the peristomal skin, as moisturizing soap may leave a residue that affects the adhesion of the skin barrier wafer.
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