A nurse is caring for a client who has a cast in place for a fractured tibia. Which of the following nursing actions is the priority immediately after the provider has applied the cast?
Performing range of motion
Checking capillary refill distal to the cast
Teaching the client about cast care
Managing pain
The Correct Answer is B
A. Performing range of motion: This should not be done immediately after applying the cast, as it may compromise the integrity of the cast. Range of motion exercises should be initiated once the cast has fully set and as directed by the healthcare provider.
B. Checking capillary refill distal to the cast: This is the priority after applying the cast. It assesses blood flow to the extremity below the cast. Impaired circulation could lead to serious complications, so it's crucial to monitor capillary refill promptly.
C. Teaching the client about cast care: While providing education about cast care is important, it is not the immediate priority. Ensuring proper circulation is more critical in the initial moments after applying the cast.
D. Managing pain: While pain management is important, it is not the immediate priority after applying the cast. Ensuring proper circulation and assessing for any signs of impairment take precedence. Pain management can be addressed once circulation is confirmed to be adequate.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hypovolemic shock is characterized by a significant loss of blood volume. While it can occur due to severe trauma, the symptoms of shortness of breath and chest pain are more indicative of a potential respiratory issue, making Fat Embolism Syndrome (FES) a higher concern in this case.
B. Correct. Given the client's recent multiple long bone fractures and the symptoms of shortness of breath and chest pain, the nurse should be concerned about the possibility of fat embolism syndrome (FES). FES can occur as a result of long bone fractures, particularly those involving the femur, pelvis, or tibia. Fat emboli can enter thebloodstream and potentially obstruct blood vessels, leading to symptoms such as shortness of breath, chest pain, and altered mental status.
C. Venous thromboembolism (VTE) is a condition involving the formation of blood clots in the veins, which can lead to complications such as deep vein thrombosis (DVT) or pulmonary embolism (PE). While this is a consideration for clients with immobilization due to fractures, it is not the primary concern in this case based on the presenting symptoms.
D. Compartment syndrome is a condition characterized by increased pressure within a muscle compartment, leading to decreased blood flow and potential tissue damage. While it can occur after fractures, it typically presents with symptoms like severe pain, swelling, and tense muscles, rather than shortness of breath and chest pain.
Correct Answer is A
Explanation
A. "Your pain will gradually become less severe." This statement is accurate and provides realistic expectations for the client. After an amputation, there will be initial post operative pain, but it should gradually decrease over time.
B. "The pain will disappear soon." This statement is not accurate. While the pain will eventually decrease, it may not completely disappear immediately after the procedure.
C. "It's likely that you will have only a tingling sensation." This statement is not accurate. While some clients may experience tingling sensations, it is not the only sensation they may feel, and this statement does not cover the full range of possible experiences.
D. "Phantom pain is mostly psychological." This statement is not accurate. Phantom pain is a real sensation that some individuals experience after an amputation. It is believed to be related to nerve endings that continue to send signals to the brain even though the limb is no longer present. It is not purely psychological.
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