A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first?
Place an ice pack over the cast.
Position the casted extremity on a pillow.
Teach the client to keep the cast clean and dry.
Palpate the pulse distal to the cast.
The Correct Answer is D
A. Place an ice pack over the cast. While this can help reduce swelling and pain, it is a comfort measure, not the priority. Safety assessments must be completed first before implementing non-urgent interventions.
B. Position the casted extremity on a pillow. Elevation is important to reduce swelling, but it follows after ensuring that circulation to the extremity is intact and that there are no signs of vascular compromise.
C. Teach the client to keep the cast clean and dry. Education is essential for long-term cast care, but it is not the first action after cast application. Immediate post-procedural monitoring takes precedence.
D. Palpate the pulse distal to the cast. The nurse should first assess for adequate circulation by checking distal pulses. This helps identify early signs of complications like compartment syndrome or impaired blood flow, making it the highest priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Social worker. While a social worker can assist with emotional or financial concerns, they are not involved in managing oxygen delivery systems or therapy adherence related to medical devices.
B. Respiratory therapist. The respiratory therapist is the most appropriate team member to consult regarding oxygen delivery methods. They can assess the client’s needs, explain alternatives (e.g., nasal cannula instead of a mask), and help promote comfort and compliance with therapy.
C. Assistive personnel. Assistive personnel can support basic care tasks, but they are not trained to adjust or manage oxygen therapy or address client concerns about medical treatments.
D. Occupational therapist. Occupational therapists assist clients in regaining independence with daily activities, not in managing oxygen therapy. This issue is outside their scope of practice.
Correct Answer is C
Explanation
A. “Take your diuretic medication with your evening meal." Taking diuretics in the evening can increase nighttime urination, worsening sleep disruption and incontinence. They should generally be taken in the morning to minimize nocturia.
B. "Decrease your intake of cranberry juice." Cranberry juice is often recommended to promote urinary tract health, though it doesn’t directly worsen urge incontinence. It is not necessary to avoid it unless advised by a provider for another reason.
C. "Plan to urinate every 3 hours while you are awake." Scheduled voiding at regular intervals is a key strategy in bladder retraining. It helps reduce urgency episodes and gradually increases bladder capacity and control over time.
D. “Limit your fluid intake to 500 milliliters per day." Severely limiting fluids can lead to dehydration, concentrated urine, and bladder irritation, potentially worsening incontinence. Adequate fluid intake should be maintained unless otherwise directed.
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