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. “I will notify my provider before taking any other medications.” - This statement reflects an understanding of the need to check for potential interactions with other medications, which is an appropriate response.
B. “I have made an appointment to see my dentist next week.” - Dental care is important, and
scheduling an appointment with the dentist is a responsible action. However, it does not indicate a misunderstanding about the medication.
C. “I will take this medication with meals.” - Taking phenytoin with meals is a correct instruction as it can help reduce gastrointestinal side effects.
D. "I'll be glad when my seizures stop so I can quit taking this medicine." - This statement
indicates a misunderstanding about the chronic nature of anti-seizure medications. The client needs further education on the importance of continuing the medication even if seizures stop.
Correct Answer is A
Explanation
a. Begin oxygen therapy: Oxygen therapy is the priority intervention for a client with a pulmonary embolism to improve oxygenation and prevent hypoxemia.
b. Start an IV infusion of lactated Ringer’s: While fluid resuscitation may be needed, oxygen therapy takes precedence to address the immediate respiratory compromise.
c. Initiate cardiac monitoring: Cardiac monitoring is important, but addressing oxygenation is the priority in a client with a pulmonary embolism.
d. Administer IV morphine: Pain management may be necessary, but the priority is to address the respiratory distress and potential hypoxemia associated with a pulmonary embolism.
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