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 B
Explanation
A. Liver function tests: While lithium can affect liver function in some cases, routine liver function tests are not typically required before administering lithium. These tests are more relevant for medications metabolized by the liver.
B. Thyroid hormone assay: This is the correct action. Regular monitoring of thyroid function, including thyroid hormone levels, is essential for clients taking lithium, as lithium therapy can lead to hypothyroidism or exacerbate preexisting thyroid conditions. Checking thyroid function before administering lithium helps ensure the client's thyroid status is within the therapeutic range and identifies any abnormalities that may require intervention.
C. Erythrocyte sedimentation rate (ESR): ESR is a nonspecific marker of inflammation and is not directly relevant to monitoring lithium therapy. While lithium can affect renal function and electrolyte balance, ESR does not specifically assess these parameters.
D. Brain natriuretic peptide (BNP): BNP is a marker of cardiac function and is not routinely monitored in clients taking lithium. While lithium can have cardiovascular effects, routine BNP testing is not necessary before administering lithium. Monitoring for cardiovascular side effects of lithium typically involves assessing for symptoms such as arrhythmias or changes in blood pressure and heart rate.
Correct Answer is B
Explanation
Rationale:
A) Administer ibuprofen as needed for pain: Ibuprofen is not typically recommended for pain relief in infants under 6 months old due to the risk of adverse effects, such as gastrointestinal irritation and renal impairment. Additionally, surgical repair of a cleft lip is not typically associated with severe postoperative pain requiring ibuprofen in infants.
B) Encourage the parents to rock the infant: This is the correct intervention. Rocking or gentle movement can provide comfort to infants postoperatively and may help soothe them. It can also promote bonding between the infant and parents, which is important for emotional support during the recovery period.
C) Offer the infant a pacifier: Pacifiers can be soothing for infants and may help provide non-nutritive sucking comfort. However, it's essential to ensure that the pacifier does not interfere with wound healing or exacerbate discomfort related to the cleft lip repair. Therefore, while offering a pacifier may be appropriate, it should be done with caution and under the guidance of the surgical team.
D) Position the infant on her abdomen: Placing the infant on her abdomen (prone position) is not recommended postoperatively, especially after cleft lip repair surgery. The supine position is typically preferred to reduce the risk of aspiration and ensure adequate airway patency. Additionally, the prone position may put pressure on the surgical site and cause discomfort.
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