A nurse is caring for a client who has a cast on their left lower leg. Which of the following actions should the nurse take?

Massage areas around the edge of the client's cast with lotion.

Avoid elevating the extremity when the client is resting in bed.

Give the client a dull object to scratch the skin under the cast.

Tell the client to report any numbness in their toes.

Answer and Explanation

The Correct Answer is D

A.   Massaging areas around the edge of the cast with lotion can introduce moisture and compromise the integrity of the cast, increasing the risk of skin breakdown and infection.
B.   Elevating the extremity when the client is resting in bed helps reduce swelling and improve circulation, promoting healing. It is an appropriate action for a client with a cast.
C.   Inserting objects under the cast can damage the skin, increase the risk of infection, or disrupt the integrity of the cast.

D. Numbness can indicate impaired circulation or nerve compression and warrants immediate assessment, making this the correct action.

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Correct Answer is D

Explanation

A. A warm extremity is not typically associated with compartment syndrome. Compartment syndrome may present with coolness due to compromised circulation.

B. Moderate pain on the ankle may be present in compartment syndrome due to increased pressure within the compartment, but it is not a specific manifestation.
C. Blanch time of 2 seconds in the toenail beds indicates normal capillary refill, which is not consistent with compartment syndrome. In compartment syndrome, capillary refill may be delayed.
D. Palpation of a weak or absent dorsalis pedis pulse is a concerning finding indicative of compromised circulation, a hallmark sign of compartment syndrome.

A. Keep initial pressure dressing in place for 1 week after surgery. B. Leave the prosthesis in place when going to bed. C. Avoid extension of the hips when lying down. D. Clean the prosthesis using a damp, soapy cloth.

Correct Answer is D

Explanation

Answer: D. "Clean the prosthesis using a damp, soapy cloth."

Rationale:

A. "Keep initial pressure dressing in place for 1 week after surgery":
The pressure dressing is typically changed more frequently to monitor the incision site for signs of infection and to ensure appropriate healing. Keeping it in place for a week without monitoring could increase the risk of infection and complications.

B. "Leave the prosthesis in place when going to bed":
It is generally recommended to remove the prosthesis at night to allow the residual limb to rest and prevent skin irritation or pressure sores. Leaving it on overnight can lead to unnecessary strain on the limb.

C. "Avoid extension of the hips when lying down":
Clients should actually avoid prolonged hip flexion, not extension, as it can lead to hip contractures. Instead, they should try to lie prone periodically to stretch the hip and reduce the risk of contracture formation.

D. "Clean the prosthesis using a damp, soapy cloth":
Using a damp, soapy cloth to clean the prosthesis helps maintain hygiene and prevents skin irritation. It's important to keep the prosthesis clean to avoid any buildup of bacteria or dirt, which can affect both the device and the residual limb’s health.

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A nurse is caring for a client who has a cast on their left lower leg. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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