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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Correct Answer is A

Explanation

A. Measure the circumference of both upper arms: This is the priority action. Swelling above the PICC insertion site could indicate infiltration or another complication. Measuring the circumference of both upper arms allows the nurse to assess the extent of swelling and monitor for any changes over time, providing valuable information for further intervention and evaluation.
B. Notify the provider who inserted the PICC line: This is an important action, but it may not be the first step. Before notifying the provider, the nurse should gather objective data by assessing the client's condition, such as measuring arm circumference, to provide a comprehensive report to the provider.
C. Remove the PICC line: This is not the first action to take. Removing the PICC line should only be considered after thorough assessment and under the direction of a healthcare provider, especially if there are signs of complications such as swelling.
D. Apply a cold pack to the client's upper arm: While applying a cold pack may help reduce swelling in some cases, it is not the priority action in this situation. The nurse should first assess the extent of swelling and gather additional data before implementing interventions such as cold therapy.

A. Increase hematocrit B. Increased temperature C. Increased heart rate D. Increased respiratory rate E. Increased blood pressure

Correct Answer is ["C","D","E"]

Explanation

A. Increase hematocrit: Fluid overload typically leads to hemodilution, resulting in a decrease in hematocrit rather than an increase. Therefore, an increase in hematocrit would not be expected in a client with fluid overload.
B. Increased temperature: Fluid overload is not typically associated with an increased body temperature. Instead, fever may indicate an infection or another underlying cause. Therefore, an increased temperature would not be a typical finding in a client with fluid overload.
C. Increased heart rate: Fluid overload can lead to an increased heart rate as the body attempts to maintain adequate cardiac output in the presence of excess fluid volume. An elevated heart rate is a compensatory mechanism to maintain tissue perfusion despite the increased workload on the heart.
D. Increased respiratory rate: Fluid overload can cause pulmonary congestion, leading to increased respiratory effort and a higher respiratory rate as the body attempts to compensate for decreased gas exchange efficiency. An increased respiratory rate helps to improve oxygenation and remove excess carbon dioxide from the body.
E. Increased blood pressure: Fluid overload often leads to increased blood pressure due to the increased volume of circulating blood, which can strain the cardiovascular system. Elevated blood pressure is a common manifestation of fluid overload and reflects the increased workload on the heart and blood vessels.

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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 caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

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