The nurse is caring for an infant with a hip spica cast who has just returned from surgery. Which nursing action will be priority for this patient?
Palpating a brachial pulse.
Assessing bilateral radial pulses.
Auscultating the heart rate apically.
Checking capillary refill in the toes.
The Correct Answer is D
Hip spica casts are typically used to immobilize the hip joint and are often used in the management of hip dysplasia or after surgery. These casts can cause restricted mobility and limit blood flow to the legs and feet, which can lead to complications such as swelling, decreased circulation, or pressure sores.
Checking capillary refill in the toes is a critical nursing intervention to assess for the presence of adequate circulation and blood flow to the affected limb. If capillary refill is slow or absent, it may indicate compromised circulation and require immediate intervention to prevent further complications.
Palpating a brachial pulse, assessing bilateral radial pulses, or auscultating the heart rate apically are not the priority nursing actions for an infant with a hip spica cast. While monitoring vital signs and circulation are important components of nursing care, the priority at this stage is to assess and manage the immediate postoperative needs of the patient, including monitoring for potential complications related to the hip spica cast.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The given observations suggest the occurrence of malignant hyperthermia (MH), a potentially life-threatening reaction to certain medications used during anesthesia. MH is characterized by an increase in heart rate (tachycardia), elevated body temperature (hyperthermia), and muscle rigidity. The primary treatment for MH is the administration of dantrolene, which is a skeletal muscle relaxant that helps to counteract the effects of the reaction.
Naloxone (Narcan) is an opioid receptor antagonist used to reverse the effects of opioid overdose or excessive opioid sedation.
Furosemide (Lasix) is a diuretic used to treat conditions such as edema and high blood pressure.
Flumazenil (Romazicon) is a benzodiazepine receptor antagonist used to reverse the effects of benzodiazepine overdose or excessive sedation.
Correct Answer is D
Explanation
Nausea and vomiting can lead to excessive loss of fluids and electrolytes, including potassium, from the body. Gastroenteritis is an inflammation of the gastrointestinal tract typically caused by viral or bacterial infections. It is commonly characterized by symptoms such as diarrhea, vomiting, abdominal pain, and fever. Antibiotics are not typically used to treat viral gastroenteritis and would not directly cause the electrolyte imbalance. Administration of IV Furosemide, a diuretic, would increase urine output but is not typically used to treat gastroenteritis. The fever itself may contribute to fluid loss but would not directly cause the electrolyte imbalance.
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