A nurse is caring for a client who has a full arm cast and reports a pain level of 8 on a scale of 0 to 10, which is unrelieved by pain medication.
Which of the following actions should the nurse plan to take first?
Check the circulation of the affected extremity.
Administer additional pain medication.
Reposition the affected extremity.
Document the findings.
The Correct Answer is A
Choice A rationale
Checking the circulation of the affected extremity is crucial because the greatest risk to the client is neuromuscular injury resulting from compartment syndrome. Compartment syndrome is a serious condition that occurs when there’s increased pressure within the muscles, leading to decreased blood flow, which can cause muscle and nerve damage. Early detection and intervention are essential to prevent permanent damage.
Choice B rationale
Administering additional pain medication might provide temporary relief, but it does not address the underlying issue of potential compartment syndrome. Pain unrelieved by medication is a key indicator of this condition, and addressing circulation is the priority.
Choice C rationale
Repositioning the affected extremity might help with comfort, but it does not address the potential for compartment syndrome. The primary concern is ensuring adequate blood flow to prevent tissue damage.
Choice D rationale
Documenting the findings is important for medical records, but it does not address the immediate risk of compartment syndrome. Immediate action to check circulation is necessary to prevent serious complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
Choice A rationale
Providing diversionary activities for the client can help distract them and reduce the likelihood of them pulling on their NG tube. Diversionary activities can include engaging the client in conversation, providing them with puzzles or games, or allowing them to watch television or listen to music. These activities can help occupy the client’s time and attention, reducing the need for restraints.
Choice B rationale
Assisting the client with toileting at frequent intervals can address any discomfort or need that may be causing the client to pull on their NG tube. Ensuring that the client is comfortable and their needs are met can reduce agitation and the likelihood of them pulling on the tube.
Choice C rationale
Involving the family in the client’s care can provide additional support and reassurance to the client. Family members can help calm the client and provide a familiar presence, which can reduce anxiety and the need for restraints.
Choice E rationale
Using an electronic bed alarm device can alert the nursing staff if the client attempts to get out of bed or pull on their NG tube. This allows for timely intervention without the need for physical restraints.
Correct Answer is A
Explanation
Choice A rationale
Eating a high fiber diet will reduce my risk for developing skin cancer. This statement is incorrect because a high fiber diet has not been proven to reduce the risk of developing skin cancer. Skin cancer is primarily caused by exposure to ultraviolet (UV) radiation from the sun or artificial sources like tanning booths.
Choice B rationale
I should check my skin monthly for any changes. This statement is correct. Regular self- examinations can help detect skin cancer early when it is most treatable. The American Academy of Dermatology recommends checking your skin from head to toe every month.
Choice C rationale
I should avoid the use of tanning booths. This statement is correct. Tanning booths emit UV radiation, which increases the risk of developing skin cancer. Avoiding tanning booths is a crucial preventive measure.
Choice D rationale
I should use sunscreen even on cloudy days. This statement is correct. UV rays can penetrate clouds, so it is essential to use sunscreen every day, regardless of the weather, to protect the skin from harmful UV radiation.
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