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 B
Explanation
Sit in a straight-backed chair. After a total hiparthroplasty, the client should avoid sitting in chairs that are too low or too soft, as they can be difficult to rise from and can risk dislocating the new hip. The clientshould apply ice to the incision site, not moist heat, in the first few dayspostoperatively. The client should avoid adducting the hip as this can also riskdislocation of the new hip joint. Hydrogen peroxide should not be used to cleanthe surgical incision, as it can delay wound healing.
Choice A: The client shouldapply ice to the incision site, not moist heat, in the first few days postoperatively.
Choice C: The client should avoid adducting the hip as this can risk dislocation ofthe new hip joint.
Correct Answer is D
Explanation
The correct answer is choice D. Allow frequent rest periods.
Choice A rationale:
Encouraging fluids is not appropriate for a client with heart failure. Clients with heart failure often experience fluid overload due to the heart’s inability to pump effectively, leading to fluid retention.Encouraging additional fluid intake can exacerbate this condition, worsening symptoms such as edema and shortness of breath.
Choice B rationale:
Measuring vital signs every 8 hours may not be frequent enough for a client with heart failure, especially if they are experiencing acute symptoms.More frequent monitoring is often necessary to detect changes in the client’s condition promptly and to manage symptoms effectively.
Choice C rationale:
Obtaining weight weekly is not sufficient for a client with heart failure. Daily weight monitoring is crucial as it helps in detecting fluid retention early.Sudden weight gain can indicate worsening heart failure and the need for adjustments in treatment.
Choice D rationale:
Allowing frequent rest periods is essential for clients with heart failure. These clients often experience fatigue and decreased exercise tolerance due to reduced cardiac output.Frequent rest periods help in managing fatigue and preventing overexertion, which can worsen heart failure symptoms.
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