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.
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Related Questions
Correct Answer is B
Explanation
A. "The proxy should manage legal issues for the client." Legal matters are outside the scope of a health care proxy’s role. The proxy is authorized only to make medical decisions and does not handle legal or court-related concerns on behalf of the client.
B. "The proxy can make treatment decisions if the client is under anesthesia." The health care proxy is activated when the client is temporarily or permanently incapacitated, such as during surgery under anesthesia. At that point, the proxy can make treatment decisions aligned with the client’s values and previously expressed wishes.
C. "The proxy can make financial decisions if the need arises." Financial decisions are the responsibility of a financial power of attorney, not a health care proxy. A DPAHC limits the proxy’s authority strictly to medical and treatment-related decisions.
D. "The proxy should make health care decisions for the client regardless of the client's ability to do so." The health care proxy is not active while the client is competent and able to make decisions. The proxy only assumes responsibility when the client lacks decision-making capacity due to illness, unconsciousness, or cognitive impairment.
Correct Answer is D,B,C,A
Explanation
D. Rolls from back to side usually occurs around 4 months of age as the infant begins developing trunk strength.
B. Rolls from back to abdomen typically follows at around 5 to 6 months, indicating improved coordination and strength.
C. Sits steadily unsupported usually develops around 8 months, showing advanced balance and postural control.
A. Changes from prone to sitting is a more complex skill that typically appears around 10 months, requiring significant core strength and motor planning.
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