A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take?
Provide reassurance to the client and parents.
Perform a neurovascular assessment.
Apply an ice pack to the casted leg
Explain the discharge instructions to the client and parents.
The Correct Answer is B
A. Provide reassurance to the client and parents: While reassurance is important, it is not the priority action when caring for an adolescent client with a newly applied fiberglass cast for a fractured tibia. Ensuring adequate neurovascular status is critical to prevent complications associated with impaired circulation or nerve function.
B. Perform a neurovascular assessment: This is the correct action and the priority when caring for a client with a newly applied cast. The nurse should assess the client's neurovascular status by evaluating circulation, sensation, and movement distal to the casted limb. Changes in color, temperature, sensation, or movement could indicate impaired circulation or nerve function, which require immediate intervention to prevent complications such as compartment syndrome.
C. Apply an ice pack to the casted leg: While applying ice may help reduce swelling and discomfort, it is not the priority action when caring for a client with a newly applied cast. Additionally, applying ice directly to the cast may not effectively reach the skin and underlying tissues, potentially causing discomfort without providing significant benefit.
D. Explain the discharge instructions to the client and parents: Providing discharge instructions is important for client education, but it is not the priority action immediately after applying a cast. Ensuring the client's safety and well-being by performing a neurovascular assessment takes precedence to identify and address any potential complications associated with the cast.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.2"]
Explanation
To calculate the volume of morphine sulfate to administer, we can use the following formula:
Volume (mL) = Dose (mg) / Concentration (mg/mL)
Plugging in the known values:
- Dose = 2 mg
- Concentration = 10 mg/mL
Volume (mL) = 2 mg / 10 mg/mL
Volume (mL) = 0.2 mL
Therefore, the nurse should administer 0.2 mL of morphine sulfate per dose.
Rounded to the nearest tenth: 0.2 mL
Correct Answer is C
Explanation
A. BP (Blood Pressure): While monitoring blood pressure is important in assessing fluid status, a decrease in blood pressure may indicate inadequate fluid resuscitation rather than adequate replacement. Hypotension may suggest ongoing hypovolemia and the need for further fluid administration.
B. Weight: Weight may provide information about fluid balance over time, but it is not an immediate indicator of adequate fluid replacement during resuscitation. Changes in weight may lag behind changes in fluid status and may not reflect real-time fluid needs.
C. Heart rate: During fluid resuscitation for severe burn injuries, one of the primary goals is to restore intravascular volume and cardiac output. As fluid replacement improves, the heart rate typically decreases, reflecting improved perfusion and reduced sympathetic response.
D. Urine output: Urine output is another critical parameter to monitor during fluid resuscitation, but a decrease in urine output could indicate inadequate fluid replacement rather than adequate replacement.
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