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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Venous thromboembolism refers to the formation of blood clots in the veins, which can lead to serious complications such as pulmonary embolism. After surgery, immobility and reduced activity can increase the risk of developing blood clots. Therefore, it is crucial to prioritize measures to prevent venous thromboembolism, such as early mobilization, compression stockings, and anticoagulant medications, to ensure the patient's safety and well-being.

A. Oral ferrous sulfate tablets. B. Cobalamin (B) Injections. C. Iron dextran infusions D. Routine blood transfusions.

Correct Answer is B

Explanation

Pernicious anemia is a type of anemia that occurs due to a lack of intrinsic factor, a protein necessary for the absorption of vitamin B12 (cobalamin) in the digestive system. As a result, patients with pernicious anemia are unable to absorb sufficient amounts of vitamin B12 from dietary sources. The treatment for pernicious anemia involves regular administration of cobalamin (B12) injections to bypass the impaired absorption and provide the necessary vitamin B12 directly.

Oral ferrous sulfate tablets are not the appropriate treatment for pernicious anemia. Ferrous sulfate is a form of iron supplement used to treat iron deficiency anemia, which is different from pernicious anemia.

Iron dextran infusions are also not indicated for pernicious anemia. Iron dextran is used for iron replacement therapy in cases of iron deficiency anemia, but it does not address the underlying issue of vitamin B12 deficiency in pernicious anemia.

Routine blood transfusions may be necessary in some cases of pernicious anemia, especially if the patient is severely anemic. However, the primary treatment for pernicious anemia is cobalamin (B12) injections, which provide the necessary vitamin B12 that the patient is unable to absorb.

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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?

Nursing Test Bank

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