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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["A","C"]

Explanation

A. Apply petroleum jelly to the client's lips after oral care: Applying petroleum jelly to the client's lips can help prevent dryness and cracking, particularly in immobile clients who may have difficulty maintaining moisture in their oral mucosa. This action helps promote comfort and prevent complications such as lip fissures and discomfort during oral care. Therefore, it is an appropriate action for the nurse to take.
B. Use the thumb and index finger to keep the client's mouth open: Forcing the client's mouth open with the thumb and index finger can be uncomfortable and may cause injury. Gentle techniques should be employed to maintain the client's mouth open if necessary, such as using a mouth prop or asking the client to open their mouth voluntarily.
C. Turn the client on his side before starting oral care: Turning the client on their side is an essential safety measure, particularly for immobile clients, to prevent aspiration and facilitate drainage of oral secretions during oral care. This position helps ensure that any excess fluid or debris can drain out of the mouth rather than pooling in the back of the throat, reducing the risk of aspiration pneumonia. Therefore, it is an appropriate action for the nurse to take.
D. Use a stiff toothbrush to clean the client's teeth: Using a stiff toothbrush can cause injury to the client's gums and oral tissues, especially if the client is immobile or has delicate oral tissues due to medical conditions or treatments. A soft-bristled toothbrush or sponge applicator should be used for oral care to avoid trauma and ensure thorough but gentle cleaning.

A. "I’m glad my child will have normal bowel movements now." B. "I want to learn how to use my child's feeding tube as soon as possible. " C. "I want to learn how to empty my child's urinary catheter bag. " D. "I'm glad that my child's ostomy is only temporary"

Correct Answer is D

Explanation

A. "I’m glad my child will have normal bowel movements now.": This statement indicates a misunderstanding of Hirschsprung disease. Surgery for Hirschsprung disease involves removing the portion of the large intestine affected by the condition, which often results in a temporary or permanent colostomy. While surgery aims to improve bowel function, it may not immediately result in normal bowel movements, especially if complications arise or additional surgeries are needed.
B. "I want to learn how to use my child's feeding tube as soon as possible.": This statement suggests a focus on enteral nutrition rather than the surgical management of Hirschsprung disease. While enteral feeding may be necessary for some children with Hirschsprung disease, the primary focus of initial surgery is to remove the affected portion of the large intestine and create an ostomy if needed, rather than addressing feeding tube use.
C. "I want to learn how to empty my child's urinary catheter bag.": This statement pertains to urinary catheter care rather than the surgical management of Hirschsprung disease. While urinary catheters may be used during surgery and recovery, they are not directly related to the treatment of Hirschsprung disease itself.
D. "I'm glad that my child's ostomy is only temporary": This statement demonstrates an understanding of the surgical management of Hirschsprung disease. Many children with Hirschsprung disease require surgery to remove the affected portion of the large intestine and create an ostomy, which may be temporary or permanent depending on the extent of the disease and the child's response to treatment. Recognizing that the ostomy is temporary indicates an understanding of the potential outcomes of surgery and the possibility of eventual bowel anastomosis.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

Correct Answer is ["A","C"]

Explanation

A nurse is providing teaching to a parent of a child who has Hirschsprung disease is scheduled for initial surgery. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is D

Explanation

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