A nurse is planning care for a client who has a radial fracture and a newly placed short arm cast on the left arm. Which of the following findings is the nurse's priority?
The client requires assistance with getting dressed.
The client reports numbness of the fingers of the left hand.
The client reports itching of the left arm.
The client has a pillow under their left arm.
The Correct Answer is B
Choice A reason: While requiring assistance with getting dressed is an important consideration in care planning, it is not the most immediate priority. The nurse should ensure that the client's basic needs are met, but this does not represent an acute medical concern.
Choice B reason: The client reporting numbness of the fingers of the left hand is the most urgent priority. Numbness can indicate neurovascular compromise or increased pressure within the cast, which could lead to further injury or complications such as compartment syndrome. Immediate assessment and intervention are required to prevent permanent damage.
Choice C reason: Itching of the left arm under the cast is a common complaint and can be uncomfortable for the client. However, it is not a priority over potential neurovascular compromise. The nurse can provide education on how to safely alleviate itching without compromising the integrity of the cast.
Choice D reason: Having a pillow under the left arm is part of proper positioning to reduce swelling and provide comfort. While it is a part of good nursing care, it is not a priority over signs of neurovascular compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Glucose Dextrose Oral (GDO) is not typically used in the immediate management of anaphylactic shock. Anaphylaxis requires rapid treatment to address severe allergic reactions and GDO does not play a role in this emergency situation.
Choice B reason: Epinephrine (Adrenaline) is the first-line treatment for anaphylactic shock. It works quickly to improve breathing, stimulate the heart, raise a dropping blood pressure, reverse hives, and reduce swelling of the face, lips, and throat.
Choice C reason: Dexamethasone (Decadron) is a corticosteroid that may be used in the treatment of anaphylaxis to reduce inflammation. However, it is not the first medication administered due to its slower onset of action compared to epinephrine.
Choice D reason: 0.9% Normal Saline is used for intravenous fluid resuscitation in anaphylactic shock but is secondary to the administration of epinephrine. It helps to maintain blood pressure and is important in the overall management but not the first medication given.
Correct Answer is B
Explanation
Choice A reason: The Mantoux skin test, also known as the tuberculin skin test, measures the immune response to the tuberculin purified protein derivative (PPD) injected under the skin. An induration of less than 1 mm is not necessarily an indication of non-infectiousness; it may indicate a lack of infection or an inadequate immune response. This test does not reflect the current infectious status as it measures a delayed hypersensitivity reaction and can remain positive for life once someone has been exposed to TB or has received the BCG vaccine.
Choice B reason: Negative sputum cultures for acid-fast bacillus are a strong indication that the client is no longer infectious. Pulmonary tuberculosis is diagnosed and monitored through sputum cultures to detect the presence of Mycobacterium tuberculosis. A series of negative cultures typically indicates that the client is not excreting the bacteria and is, therefore, not contagious.
Choice C reason: While the cessation of coughing up blood-tinged sputum is a positive sign of clinical improvement, it does not conclusively indicate that the client is no longer infectious. The absence of blood in the sputum may simply mean that the damage to lung tissues is healing, but the client could still be harboring and potentially spreading TB bacteria.
Choice D reason: The Quantiferon-TB Gold test is a blood test that measures the immune system's response to TB bacteria. A positive result indicates TB infection, but it does not distinguish between latent infection and active disease, nor does it provide information on infectiousness. The parenthetical "negative" is confusing and should be clarified in the context of the test results.
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