A nurse is caring for a client who has a cast on their left lower leg. Which of the following actions should the nurse take?

Massage areas around the edge of the client's cast with lotion.

Avoid elevating the extremity when the client is resting in bed.

Give the client a dull object to scratch the skin under the cast.

Tell the client to report any numbness in their toes.

Answer and Explanation

The Correct Answer is D

A.   Massaging areas around the edge of the cast with lotion can introduce moisture and compromise the integrity of the cast, increasing the risk of skin breakdown and infection.
B.   Elevating the extremity when the client is resting in bed helps reduce swelling and improve circulation, promoting healing. It is an appropriate action for a client with a cast.
C.   Inserting objects under the cast can damage the skin, increase the risk of infection, or disrupt the integrity of the cast.

D. Numbness can indicate impaired circulation or nerve compression and warrants immediate assessment, making this the correct action.

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Correct Answer is D

Explanation

A. Platelets within the normal range indicate appropriate clotting function and are not concerning in this scenario.
B. Red blood cell (RBC) count within the normal range suggests normal oxygen-carrying capacity and is not directly related to the client's symptoms.
C. Hemoglobin (Hgb) level within the normal range indicates adequate oxygen-carrying capacity and is not directly related to the client's symptoms.
D. An international normalized ratio (INR) of 5.2 is significantly elevated and indicates that the client's blood is not clotting properly. This could be a result of excessive anticoagulation from heparin therapy, which may lead to bleeding complications such as bloody stools. Therefore, the nurse should report this finding to the provider for further evaluation and possible adjustment of the anticoagulant therapy.

A. Call EMS if a seizure lasts 5 min or more. B. Restrain the child at the onset of the seizure. C. Offer the child a bubble bath every evening. D. Place the child in a prone position during the seizure.

Correct Answer is A

Explanation

A. This is the correct answer. Seizures lasting longer than 5 minutes can be indicative of status epilepticus, a medical emergency requiring immediate intervention.
B. Restraint during a seizure can cause injury to the child and is not recommended. Instead, it's important to ensure the child's safety by removing nearby objects and gently guiding them to the floor if possible.
C. Offering a bubble bath every evening is not relevant to seizure care and does not contribute to the child's safety or well-being.
D. Placing the child in a prone position during a seizure can obstruct the airway and increase the risk of aspiration. The child should be placed in a lateral recumbent position to maintain an open airway and prevent injury.

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A nurse is caring for a client who has a cast on their left lower leg. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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