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 ["1.4"]
Explanation
We know that 7,000 units is equivalent to 5,000 units per ml. So, we can set up the proportion:
7,000 units / 5,000 units per ml = x ml / 1 ml x = 7,000 / 5,000
x = 1.4
Therefore, the nurse should administer 1.4 milliliters (ml) of heparin.
Correct Answer is B
Explanation
Excess body weight, particularly in the abdominal area, can increase intra-abdominal pressure and lead to the weakening of the lower esophageal sphincter (LES). The LES is responsible for preventing stomach acid from flowing back into the esophagus. When it becomes weakened, it can contribute to the development of GERD. Other risk factors for GERD include certain dietary choices, such as consuming fatty and spicy foods, smoking, pregnancy, and alcohol consumption.
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