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 D

Explanation

Answer: D

Rationale:

A. The American Hospital Association requires accredited facilities to have protocols in place requiring medication reconciliation: The American Hospital Association does advocate for medication reconciliation as part of safety protocols, but the primary focus of medication reconciliation is not solely based on AHA requirements. It is more about improving patient safety and preventing errors.

B. The nurse who performs medication reconciliation is demonstrating the ethical principle of veracity: While medication reconciliation involves accurate and truthful communication, it primarily serves to ensure safety and accuracy in medication management rather than directly demonstrating the ethical principle of veracity.

C. The International Council of Nurses Code of Ethics stipulates that the nurse performs medication reconciliation when a client is admitted to a facility, is transferred to another facility, and when a client is discharged from a facility: Although medication reconciliation is crucial at these points of care transition, the International Council of Nurses Code of Ethics does not explicitly mandate this process.

D. The purpose of medication reconciliation is to prevent adverse medication reactions: Medication reconciliation aims to ensure accurate medication lists and prevent errors, which in turn helps prevent adverse medication reactions. This aligns with the primary goal of the process, which is to enhance medication safety.

Correct Answer is ["2"]

Explanation

Here's how we can find the desired flow rate:

Total volume to infuse (in minutes):
- We need to convert the infusion time from hours to minutes.
- Time (minutes) = Time (hours) x 60 minutes/hour
- Time (minutes) = 2 hours x 60 minutes/hour
- Time (minutes) = 120 minutes
Total volume to infuse (in mL):
- Given volume = 250 mL
Drop factor (gtts/mL):
- Given drop factor = 15 gtts/mL
Flow rate (gtts/minute):
- Flow rate = Total volume (mL) / Time (minutes) x Drop factor (gtts/mL)
- Flow rate = 250 mL / 120 minutes x 15 gtts/mL

To simplify the calculation, we can divide all values by 5 (as long as we perform the division on both sides of the equation, the answer won't change):

Flow rate = (250 mL / 5) / (120 minutes / 5) x (15 gtts/mL / 5)
Flow rate = 50 mL / 24 minutes x 3 gtts/mL
Flow rate = 2.0833... gtts/minute (round to nearest whole number)

Rounded flow rate (gtts/minute):
- Flow rate = 2 gtts/minute

Therefore, the nurse should adjust the flow rate to deliver approximately 2 gtts/minute.

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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 on a medical-surgical unit is reconciling a newly admitted client's medication. The nurse is reviewing the process of medication reconciliation with a newly licensed nurse. The nurse should include which of the following information?

Correct Answer is D

Explanation

Correct Answer is ["2"]

Explanation

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