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. Was hit by another soccer player on the field - This suggests a possible collision injury, which may result in various types of leg or foot injuries, but it doesn't specifically point to an ankle sprain.
B. Twisted his foot while running bases during a baseball game - This mechanism of injury is consistent with an ankle sprain. Twisting the foot during a sudden movement can cause stretching or tearing of ligaments around the ankle.
C. Has ankle pain after running a 16 km (10 mile) race - This suggests an overuse or strain injury, which could include various types of leg injuries, but it doesn't specifically point to an ankle sprain.
D. Dropped a 4.5 kg (10 lb) weight on his lower leg at a health club - This suggests a potential crush or impact injury to the lower leg, which may result in various types of leg injuries, but it doesn't specifically point to an ankle sprain.
Correct Answer is B
Explanation
A. Positioning the client in a high-Fowler's position if clear drainage is noted on the dressing is not a specific intervention for a laminectomy with spinal fusion. The nurse should follow the surgeon's specific postoperative orders regarding positioning and wound care.
B. Monitoring sensory perception of the lower extremities is a crucial nursing intervention after a laminectomy with spinal fusion. This is to assess for any signs of neurovascular compromise or nerve damage.
C. Assisting the client into the knee-chest position to manage postoperative discomfort is not a recommended position after a laminectomy with spinal fusion. The nurse should follow the surgeon's specific postoperative orders regarding positioning.
D. Maintaining strict bed rest for the first 48 hours postoperative is not typically indicated after a laminectomy with spinal fusion. Early mobilization and ambulation are often encouraged to prevent complications and promote recovery. The nurse should follow the surgeon's specific postoperative orders regarding activity and mobility.
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