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 D
Explanation
Cholelithiasis refers to the presence of gallstones in the gallbladder or bile ducts. The most common symptom is right upper quadrant abdominal pain, which may be colicky or steady. Nausea and vomiting are also commonly associated with cholelithiasis.
Coffee ground emesis and constipation are not typical findings associated with cholelithiasis. Absent bowel sounds may be a sign of bowel obstruction but are not specific to cholelithiasis.
Correct Answer is C
Explanation
Morphine is a potent opioid analgesic that can depress the respiratory system. Respiratory depression is a potential adverse effect of morphine, and it is essential for the nurse to monitor the patient's respiratory rate regularly to ensure adequate oxygenation and prevent respiratory complications.
By checking the respiratory rate, the nurse can assess if the patient is breathing adequately and detect any signs of respiratory depression. If the respiratory rate is significantly decreased or the patient shows signs of respiratory distress (e.g., shallow or irregular breathing), immediate intervention is necessary to address the situation promptly.
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