nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following actions is best for the nurse to take?
Perform a neurovascular assessment.
Provide reassurance to the client and parents.
Apply an ice pack to the casted leg.
Explain the discharge instructions to the client and parents.
The Correct Answer is A
A. Perform a neurovascular assessment: This is the correct answer. After a cast is applied, it’s crucial to regularly assess the client’s neurovascular status (sensation, movement, temperature, color, and capillary refill) to ensure that the cast is not too tight and that circulation is not compromised.
B. Provide reassurance to the client and parents: While this is important, the immediate priority is to ensure the client’s physical well-being.
C. Apply an ice pack to the casted leg: This can help reduce swelling and pain, but it’s not the immediate priority. The nurse first needs to ensure that the cast is not compromising circulation or nerve function.
D. Explain the discharge instructions to the client and parents: This is typically done later, closer to the time of discharge. The immediate priority is to assess the client’s physical condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Increased urine output: This is not typically associated with heart failure. In fact, decreased urine output may occur due to reduced kidney perfusion.
B. Weight loss: While weight loss can occur in heart failure, it’s more common in adults than in children. In children, especially toddlers, weight gain or failure to thrive might be observed due to fluid retention or poor nutrition absorption.
C. Bradycardia: This is not typically a sign of heart failure. In heart failure, the heart rate is often increased (tachycardia) as the heart tries to compensate for its decreased pumping efficiency.
D. Orthopnea: This is the correct answer. Orthopnea, or difficulty breathing when lying flat, is a common symptom of heart failure. It occurs because when the body is in a horizontal position, fluid in the body is redistributed, leading to increased fluid in the lungs and difficulty breathing.
Correct Answer is D
Explanation
Answer: D. Maintains a dry dressing over the sac
A. Places the infant in a side-lying position.
Placing the infant in a side-lying position is not the most appropriate action for a child with myelomeningocele. It is often recommended to position infants in a supine (on their back) or prone (on their stomach) position to prevent pressure on the sac and facilitate optimal positioning for spinal alignment and care.
B. Takes an axillary temperature.
While taking an axillary temperature is a common practice for infants, it is not specific to the care of an infant with myelomeningocele. In fact, rectal temperatures are often preferred in clinical settings for more accurate readings in infants, particularly if there are concerns about infection or significant illness.
C. Performs range of motion on the infant's hips.
Performing range of motion exercises on the infant's hips may be appropriate for some infants but should be done cautiously in those with myelomeningocele. Depending on the extent of nerve damage, the infant may have limited mobility or lack sensation in the lower extremities, and inappropriate exercises could risk injury or further complications.
D. Maintains a dry dressing over the sac.
Maintaining a dry dressing over the sac is a critical action in the care of an infant with myelomeningocele. This condition involves a defect in the spinal column where the spinal cord and surrounding nerves protrude through the back, making the area susceptible to infection and injury. Keeping the dressing dry and intact protects the sac and prevents infection, indicating that the newly licensed nurse understands the importance of this essential nursing intervention.
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