A nurse is caring for a client who has a distal radius fracture with a short arm cast applied. Which of the following actions should the nurse take?
Use a hair dryer to blow hot air into the cast to relieve itching.
Perform neurovascular checks of the affected extremity every 2 hr.
Position the fractured arm below the level of the client's heart.
Immobilize the client's fingers using a hand splint.
The Correct Answer is B
The nurse should perform neurovascular checks of the affected extremity every 2 hours to monitor for any signs of compartment syndrome or impaired circulation. It is important to assess for the five Ps: pain, pulse, pallor, paresthesia, and paralysis. Using a hair dryer to relieve itching can cause burns and is not a recommended intervention. Positioning the fractured arm below the level of the client's heart can increase swelling and exacerbate pain. Immobilizing the client's fingers using a hand splint is not indicated unless there is a finger fracture or injury.
Choice A (Use a hair dryer to blow hot air into the cast to relieve itching) is not an answer because it can cause burns and is not a recommended intervention.
Choice C (Position the fractured arm below the level of the client's heart) is not an answer because it can increase swelling and exacerbate pain.
Choice D (Immobilize the client's fingers using a hand splint) is not an answer because it is not indicated unless there is a finger fracture or injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A, "Cover the pad prior to use." This is a necessary precaution to prevent burns. Choice B is incorrect because filling the pad with sterile water is not necessary. Choice C is incorrect because aquathermia pads should only be applied for 20-30 minutes at a time. Choice D is incorrect because using safety pins to secure the pad in place can puncture the pad and cause burns. Choice B is not correct because filling the pad with sterile water is not necessary. Choice C is not correct because aquathermia pads should only be applied for 20-30 minutes at a time. Choice D is not correct because using safety pins to secure the pad in place can puncture the pad and cause burns.
Correct Answer is D
Explanation
Palpable area of induration, greater than 10 mm (0.4 in) in diameter. This indicates a positive tuberculin skin test (TST) reaction for a person with no known risk factors for TB infection. A positive TST reaction means that the person has been infected with Mycobacterium tuberculosis, the bacterium that causes TB disease, and needs further testing to confirm the diagnosis and rule out active TB disease.
The other choices are not correct because:
- Choice A. Nonpalpable area of redness, less than 5 mm (0.2 in) in diameter. This indicates a negative TST reaction for any person, regardless of their risk factors for TB infection. A negative TST reaction means that the person has not been infected with Mycobacterium tuberculosis or has a very low level of immune response to the bacterium.
- Choice B. Area of ecchymosis, greater than 12 mm (0.5 in) in diameter. This indicates a bruise or bleeding under the skin, not a TST reaction. Ecchymosis is not caused by the injection of tuberculin purified protein derivative (PPD) into the skin, but by trauma or injury to the blood vessels.
- Choice C. Tenderness at the injection site. This indicates a mild local reaction to the injection of tuberculin PPD into the skin, not a TST reaction. Tenderness is not measured in millimeters of induration (firm swelling), which is the standard way of reading TST results.
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