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 C

Explanation

A. Asking the client if they have talked to their parents about their anxiety may not be appropriate, as it assumes the client is comfortable discussing their concerns with their parents. It's important to establish rapport and trust with the client before delving into personal matters such as family dynamics.
B. Asking "Why do you think you are so anxious?" may come across as confrontational and put the client on the defensive. It's important to approach the client's concerns with empathy and understanding rather than seeking an explanation for their anxiety.
C. This response acknowledges the client's feelings and validates their experience, showing empathy and understanding. It opens the door for further exploration of the client's concerns and allows the nurse to provide support and assistance.
D. While assessing the duration of symptoms is important, asking "How long has this been going on?" as an initial response may feel dismissive to the client's current distress. Starting with an empathetic acknowledgment of the client's experience can help build rapport and trust before delving into more specific questions about the duration and severity of symptoms.

A. Clear the respiratory tract B. Cut the umbilical cord C. Stimulate the infant to cry D. Dry the infant off and cover the head

Correct Answer is A

Explanation

A. Clear the respiratory tract: This is the correct action. Clearing the newborn's respiratory tract is the priority immediately after delivery to ensure adequate breathing. The nurse should suction the mouth and nose with a bulb syringe to remove any mucus or amniotic fluid and facilitate effective respiration.
B. Cut the umbilical cord: Cutting the umbilical cord is an important step in newborn care, but it is typically done after ensuring the newborn's immediate respiratory needs are met. The priority immediately after delivery is to establish effective breathing.
C. Stimulate the infant to cry: While stimulating the infant to cry can help clear the airways and establish effective breathing, it should be done concurrently with clearing the respiratory tract. Therefore, clearing the respiratory tract takes precedence over stimulating the infant to cry.
D. Dry the infant off and cover the head: Drying the infant and covering the head are important steps in newborn care to prevent heat loss and maintain thermal regulation. However, these actions can be done after ensuring the newborn's respiratory tract is clear and breathing is established.

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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?

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