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 C
Explanation
Weight gain is a positive indicator of improved nutritional status. It suggests that the client is receiving adequate nutrition and their body is able to build up and retain weight. This is particularly important in the case of protein-calorie malnutrition, as it indicates that the client is receiving sufficient protein and calories to support their nutritional needs.
Correct Answer is ["C","D","E"]
Explanation
The nurse explains that immobilizing a fracture will:
- Help align the bone fragments and reduce movement, which is crucial for proper healing. Immobilization can help maintain the stability of the fracture site, allowing the bones to knit together and heal.
- Help to minimize movement and subsequent pain. It provides support and reduces stress on the injured area, which can help alleviate discomfort and promote a more comfortable healing process.
- Help to minimize movement and reduce the risk of fat globules from bone marrow entering the bloodstream and causing a fat embolism, a potentially serious complication.
Preventing blood clots, preventing malignant hyperthermia, and immobilizing a fracture are not directly related. Preventing blood clots typically involves other measures such as early mobilization, elevation, and medication to prevent deep vein thrombosis. Malignant hyperthermia is a rare, potentially life-threatening reaction to certain medications used during anesthesia, and immobilization does not directly prevent it.
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