The nurse is caring for a client with a fractured femur. Following removal of traction and the application of a full-leg cast, which action should the nurse prioritize?
Pain management.
Ambulation teaching.
Leg elevation.
Neurovascular checks.
The Correct Answer is D
A. Pain management is important but should follow the assessment of any immediate complications.
B. Ambulation teaching is important but is not the first priority immediately after cast application.
C. Leg elevation can help with swelling but is not the immediate priority.
D. Neurovascular checks are crucial to assess for complications such as compartment syndrome, which can occur after cast application. Early detection of neurovascular impairment is essential to prevent long-term damage.
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Related Questions
Correct Answer is B
Explanation
A. Initiating sequential pneumatic compression devices is not immediately relevant to managing acute stroke symptoms.
B. Raising the head of the bed to 30 degrees and keeping the head and neck in neutral alignment helps reduce intracranial pressure and facilitates venous drainage, which is crucial in managing potential stroke patients.
C. Elevating the dependent joints on the affected side is not immediately necessary and does not address the acute neurological symptoms.
D. While obtaining a focused history is important, it should follow after initial stabilization measures such as positioning and securing immediate diagnostic tests.
Correct Answer is ["A","C","D","E"]
Explanation
A. Auscultating bowel sounds in all quadrants helps assess the extent of gastrointestinal involvement and possible complications.
B. Administering warfarin is not appropriate in this acute situation where there may be active bleeding; instead, the heparin infusion should be stopped.
C. Assessing the characteristics of the pain is crucial for determining the severity and possible source of the gastrointestinal symptoms.
D. Monitoring stools for the presence of blood is essential to confirm gastrointestinal bleeding and the extent of blood loss.
E. Reviewing the last partial thromboplastin time results helps assess the anticoagulation status of the client and the potential need for reversal.
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