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 C
Explanation
A. "My child must be free from this before returning to school": While it's important for the child to be treated and free from head lice before returning to school, this statement alone doesn't address the comprehensive measures needed to eradicate pediculosis capitis. It focuses only on the child's return to school without considering other aspects of treatment and prevention.
B. "Toys that can't be dry cleaned or washed must be thrown out": Throwing out toys that can't be dry cleaned or washed is an extreme measure and unnecessary for managing pediculosis capitis. While cleaning items that come into contact with the child's head is important, it's not necessary to dispose of toys unless they cannot be effectively cleaned.
C. "All recently used clothing, bedding, and towels must be washed in hot water": This statement indicates a thorough understanding of the teaching. Washing recently used clothing, bedding, and towels in hot water is an essential step in eliminating head lice and preventing reinfestation. Hot water helps kill lice and their eggs, reducing the risk of transmission.
D. "I will treat all the family members to be on the safe side": Treating all family members is a prudent measure to prevent the spread of head lice within the household. However, this statement alone doesn't address other important aspects of treatment and prevention, such as washing bedding and clothing. While treating family members is important, it's only one part of a comprehensive approach to managing pediculosis capitis.
Correct Answer is D
Explanation
A. Delayed gastric emptying is not associated with decreased breath sounds in the lower lobes of the lungs. It is more commonly associated with gastrointestinal symptoms such as bloating and nausea.
B. While pulmonary edema can cause respiratory symptoms, such as crackles and wheezes, decreased breath sounds in the lower lobes are not typically indicative of pulmonary edema. Pulmonary edema is more commonly associated with fluid accumulation in the lungs, leading to crackles and other signs of fluid overload.
C. An upper respiratory infection primarily affects the upper airways, such as the nose and throat, and typically presents with symptoms such as nasal congestion, sore throat, and cough. It is not typically associated with decreased breath sounds in the lower lobes of the lungs.
D. Atelectasis refers to the collapse or closure of a part of the lung, leading to decreased air entry and breath sounds in the affected area. In a client who has been on bedrest for several days, atelectasis can occur due to reduced lung expansion and ventilation. Decreased breath sounds in the lower lobes are a common finding in atelectasis, especially when the condition affects the bases of the lungs, as gravitational forces can exacerbate the collapse of lung tissue in dependent areas. Therefore, this finding is most consistent with atelectasis.
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