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A client is experiencing numbness and tingling distal to a new arm cast with no increase in pain. The nurse assesses that the client's fingers are pale, cool, and swollen. What action does the nurse take next?
Encourage range of motion
Apply heat to the affected hand
Remove the cast to decrease pressure
Raise the arm above the level of the heart
The Correct Answer is C
Choice A reason: This is not the best action because encouraging range of motion can worsen the symptoms and cause more damage to the nerves and blood vessels. Range of motion is the movement of the joints and muscles through their normal extent. Range of motion can help to prevent stiffness, contractures, and muscle atrophy, but it can also increase the swelling and pressure in the affected area, which can impair the circulation and sensation.
Choice B reason: This is not the best action because applying heat to the affected hand can worsen the symptoms and cause more damage to the tissues. Heat is the transfer of thermal energy from a warmer object to a cooler one. Heat can help to relax the muscles, reduce the pain, and increase the blood flow, but it can also increase the inflammation and edema in the affected area, which can compromise the oxygen and nutrient delivery to the tissues.
Choice C reason: This is the best action because removing the cast can decrease the pressure and restore the circulation and sensation to the affected area. A cast is a rigid device that immobilizes and protects a fractured or injured body part. A cast can help to align the bones, prevent displacement, and promote healing, but it can also cause complications, such as compartment syndrome, infection, or nerve damage. Compartment syndrome is a condition where the pressure inside the muscles increases to dangerous levels, causing severe pain, reduced blood flow, and tissue death. The nurse should remove the cast immediately and notify the physician if the client shows signs of compartment syndrome, such as numbness, tingling, pallor, coolness, or swelling.
Choice D reason: This is not the best action because raising the arm above the level of the heart can worsen the symptoms and cause more damage to the nerves and blood vessels. Raising the arm above the level of the heart can help to reduce the swelling and pain in the affected area, but it can also reduce the blood flow and oxygenation to the area, which can lead to ischemia, necrosis, or gangrene. The nurse should elevate the arm at or below the level of the heart and monitor the pulse, color, temperature, and sensation of the fingers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A reason: Obtaining a PAPR mask is not a step in preparing a sterile field. A PAPR mask is a powered airpurifying respirator that protects the wearer from airborne contaminants. It is not required for setting up a sterile field, unless the client has a highly infectious disease.
Choice B reason: Do not turn away from the sterile field is a step in preparing a sterile field. Turning away from the sterile field can contaminate the field or the items on it. The nurse should always face the sterile field and keep it in view.
Choice C reason: Add items to the sterile field by dropping them gently is a step in preparing a sterile field. Dropping items gently onto the sterile field prevents splashing or touching the field or the items. The nurse should open the sterile packages away from the field and drop the items close to the edge of the field.
Choice D reason: Covering the sterile field once it is set up is not a step in preparing a sterile field. Covering the sterile field can compromise its sterility and create moisture that can harbor microorganisms. The nurse should not cover the sterile field unless it is necessary to move it or store it for later use.
Choice E reason: Preparing the client before setting up the sterile field is a step in preparing a sterile field. Preparing the client involves explaining the procedure, obtaining consent, providing privacy, and positioning the client. The nurse should prepare the client before setting up the sterile field to avoid leaving the field unattended or exposing it to the client's body fluids.
Correct Answer is B
Explanation
Choice A reason: Providing the client with antipyretic therapy is not the nurse's priority. Antipyretic therapy is a treatment that lowers the body temperature and reduces fever. Fever is a common symptom of acute osteomyelitis, which is a bacterial infection of the bone and bone marrow. Antipyretic therapy may help to relieve the discomfort and inflammation caused by fever, but it does not address the underlying cause of the infection.
Choice B reason: Administering antibiotics to the client is the nurse's priority. Antibiotics are medications that kill or inhibit the growth of bacteria. Antibiotics are the main treatment for acute osteomyelitis, as they target the specific type of bacteria that is causing the infection. Antibiotics can prevent the spread of the infection to other bones or organs and reduce the risk of complications, such as chronic osteomyelitis, septic arthritis, or sepsis.
Choice C reason: Increasing the client's protein intake is not the nurse's priority. Protein intake is a nutritional factor that affects the wound healing and immune system. Protein is composed of amino acids, which are the building blocks of cells and tissues. Protein intake can enhance the repair and regeneration of the bone and the soft tissues that are damaged by the infection. Protein intake can also support the immune system's ability to fight off the infection. However, protein intake alone is not sufficient to treat acute osteomyelitis, as it does not eliminate the bacteria that are causing the infection.
Choice D reason: Teaching relaxation breathing to reduce the client's pain is not the nurse's priority. Relaxation breathing is a technique that involves deep and slow breathing that helps to relax the body and mind. Relaxation breathing can help to reduce the pain and stress that are associated with acute osteomyelitis. Pain is a common symptom of acute osteomyelitis, which is caused by the inflammation and pressure on the bone and the surrounding tissues. Relaxation breathing can help to ease the pain and improve the mood and quality of life of the client. However, relaxation breathing alone is not enough to treat acute osteomyelitis, as it does not address the source of the pain.
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