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.
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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
The client's symptoms of bounding peripheral pulses, weight gain, pitting edema, and moist crackles bilaterally suggest fluid volume overload or fluid retention. Furosemide (Lasix) is a loop diuretic that helps to promote diuresis and reduce fluid volume. Administering the medication promptly can help address the client's symptoms and alleviate the fluid overload.
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