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
Opioid tolerance occurs when the body becomes less responsive to the effects of opioids over time. This means that higher doses of the medication are needed to achieve the same level of pain relief that was previously achieved with lower doses. Opioid tolerance is a common phenomenon in long-term opioid therapy and can occur in patients who have been using opioids for an extended period.
Opioid abstinence syndrome, also known as opioid withdrawal, refers to the set of symptoms that occur when a person abruptly stops or reduces their use of opioids after developing physical dependence.
Opioid toxicity refers to the harmful effects that occur when an individual takes an excessive dose of opioids, leading to potentially life-threatening complications. It is characterized by symptoms such as respiratory depression, sedation, pinpoint pupils, and decreased level of consciousness.
Opioid addiction is a complex condition characterized by compulsive drug-seeking behavior, loss of control over opioid use, and continued use despite negative consequences.
Correct Answer is ["Lithotripsy"," Encourage increased fluid intake"]
Explanation
Lithotripsy and Encourage increased fluid intake are the most important interventions.
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