A nurse is caring for a child following an open reduction and internal fixation of a fractured femur and application of a cast. The cast has a window cut in it for viewing of the incision. Which of the following actions should the nurse take first?
Turn the client so the cast will dry on all sides.
Remove the window and view the incision.
Medicate the client for pain.
Perform neurovascular checks of the affected extremity.
The Correct Answer is D
a. Turn the client so the cast will dry on all sides: While ensuring the cast is dry is important, the first priority following a surgical procedure is to assess neurovascular status to detect any
complications.
b. Remove the window and view the incision: Removing the window may compromise the cast's integrity, and the priority is to assess neurovascular status before inspecting the incision.
c. Medicate the client for pain: Pain management is important, but assessing neurovascular status is the initial priority to ensure there are no complications affecting circulation.
d. Perform neurovascular checks of the affected extremity: Neurovascular checks are the priority to detect any signs of impaired circulation or nerve function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
a. "This test will inform your provider if you are anemic." Serum creatinine is not used to assess anemia. Anemia is often evaluated through tests like hemoglobin and hematocrit.
b. "This test will inform your provider if you have an infection." Serum creatinine is not a direct indicator of infection. It is primarily used to assess kidney function.
c. "This test will inform your provider if you have a thyroid disorder." Serum creatinine is not
used to evaluate thyroid function. Thyroid function is typically assessed through thyroid function tests.
d. "This test will inform your provider how your kidneys are functioning." This is the correct
response. Serum creatinine is a waste product that is filtered by the kidneys, and elevated levels may indicate impaired renal function.
Correct Answer is C
Explanation
a. Battle's sign: Battle's sign is bruising over the mastoid process and is not a direct manifestation of increased intracranial pressure.
b. Nuchal rigidity: Nuchal rigidity (stiff neck) is associated with irritation of the meninges and is not a specific sign of increased intracranial pressure.
c. Lethargy: Lethargy or altered level of consciousness is a common manifestation of increased intracranial pressure. It can range from mild drowsiness to severe impairment of consciousness.
d. Polyuria: Polyuria is not a typical manifestation of increased intracranial pressure. Increased urine output may be associated with other conditions, such as diabetes or diuretic use.
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