A nurse is caring for a client who has a full arm cast and reports a pain level of 8 on a scale of 0 to 10, which is unrelieved by pain medication.
Which of the following actions should the nurse plan to take first?

Check the circulation of the affected extremity.

Administer additional pain medication.

Reposition the affected extremity.

Document the findings.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Checking the circulation of the affected extremity is crucial because the greatest risk to the client is neuromuscular injury resulting from compartment syndrome. Compartment syndrome is a serious condition that occurs when there’s increased pressure within the muscles, leading to decreased blood flow, which can cause muscle and nerve damage. Early detection and intervention are essential to prevent permanent damage.

Choice B rationale

Administering additional pain medication might provide temporary relief, but it does not address the underlying issue of potential compartment syndrome. Pain unrelieved by medication is a key indicator of this condition, and addressing circulation is the priority.

Choice C rationale

Repositioning the affected extremity might help with comfort, but it does not address the potential for compartment syndrome. The primary concern is ensuring adequate blood flow to prevent tissue damage.

Choice D rationale

Documenting the findings is important for medical records, but it does not address the immediate risk of compartment syndrome. Immediate action to check circulation is necessary to prevent serious complications.

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Correct Answer is A

Explanation

Choice A rationale

Lying on the left side can help minimize the effects of reflux during sleep. This position helps keep the stomach contents lower than the esophagus, reducing the likelihood of acid reflux.

Choice B rationale

Lying on the right side can increase the risk of acid reflux. This position allows the stomach contents to flow more easily into the esophagus, exacerbating reflux symptoms.

Choice C rationale

Sleeping on the back with the head flat can worsen reflux symptoms. This position allows stomach acid to flow back into the esophagus more easily, increasing the risk of reflux.

Choice D rationale

Sleeping on the stomach with the head flat is not recommended for clients with GERD. This position can increase pressure on the stomach, promoting acid reflux into the esophagus.

A. Use friction when washing the affected area. B. Use a new cosmetic pad with each limited application of makeup. C. Use an oil-based soap to wash affected areas daily. D. Express the larger comedones periodically.

Correct Answer is B

Explanation

Choice A rationale

Using friction when washing the affected area can irritate the skin and worsen acne. Gentle cleansing is recommended to avoid aggravating the condition.

Choice B rationale

Using a new cosmetic pad with each limited application of makeup helps prevent the spread of bacteria and reduces the risk of further clogging pores, which can exacerbate acne.

Choice C rationale

Using an oil-based soap can clog pores and worsen acne. Non-comedogenic, water-based cleansers are recommended for acne-prone skin.

Choice D rationale

Expressing larger comedones periodically can lead to skin damage and scarring. It is better to use appropriate acne treatments to manage comedones.

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A nurse is caring for a client who has a full arm cast and reports a pain level of 8 on a scale of 0 to 10, which is unrelieved by pain medication. Which of the following actions should the nurse plan to take first?

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A nurse is caring for a client who has a full arm cast and reports a pain level of 8 on a scale of 0 to 10, which is unrelieved by pain medication.
Which of the following actions should the nurse plan to take first?