A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take?
Provide reassurance to the client and parents.
Perform a neurovascular assessment.
Apply an ice pack to the casted leg
Explain the discharge instructions to the client and parents.
The Correct Answer is B
A. Provide reassurance to the client and parents: While reassurance is important, it is not the priority action when caring for an adolescent client with a newly applied fiberglass cast for a fractured tibia. Ensuring adequate neurovascular status is critical to prevent complications associated with impaired circulation or nerve function.
B. Perform a neurovascular assessment: This is the correct action and the priority when caring for a client with a newly applied cast. The nurse should assess the client's neurovascular status by evaluating circulation, sensation, and movement distal to the casted limb. Changes in color, temperature, sensation, or movement could indicate impaired circulation or nerve function, which require immediate intervention to prevent complications such as compartment syndrome.
C. Apply an ice pack to the casted leg: While applying ice may help reduce swelling and discomfort, it is not the priority action when caring for a client with a newly applied cast. Additionally, applying ice directly to the cast may not effectively reach the skin and underlying tissues, potentially causing discomfort without providing significant benefit.
D. Explain the discharge instructions to the client and parents: Providing discharge instructions is important for client education, but it is not the priority action immediately after applying a cast. Ensuring the client's safety and well-being by performing a neurovascular assessment takes precedence to identify and address any potential complications associated with the cast.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Answer: B
Rationale:
A. Radial vein in the wrist: The radial vein is not commonly used for IV catheter insertion due to its location and size. The wrist veins can be smaller and more difficult to cannulate compared to veins in the forearm or antecubital area.
B. Median vein in the forearm: The median vein in the forearm is a preferred site for IV catheter insertion in older adults. It is generally more accessible and less prone to complications than veins in the hand or wrist, making it a suitable choice for stable, longer-term access.
C. Dorsal metacarpal vein: While the dorsal metacarpal veins on the hand can be used for IV insertion, they are typically smaller and more difficult to access than veins in the forearm. Additionally, veins in the hand can be more prone to irritation and complications.
D. Ante-cubital vein: The antecubital vein (such as the median cubital vein) is a good site for IV insertion due to its size and accessibility, especially for larger gauge catheters or when longer-term access is needed. However, it is often preferred for more acute situations rather than routine outpatient procedures.
Correct Answer is C
Explanation
A. Tell the child it is candy: Deceiving the child by telling them medication is candy can lead to trust issues and may cause confusion if the child later discovers the truth. It's important to promote honesty and transparency in healthcare interactions.
B. Tell the child he will have to have a shot instead: Threatening the child with a shot as an alternative to taking medication can induce fear and anxiety, making the child more resistant to cooperation. Using fear as a motivator can have negative psychological effects and should be avoided.
C. Offer the child a choice of taking the medication with juice or water: This strategy empowers the child by giving them a sense of control and autonomy over the situation. Offering choices can help the child feel more involved in their care and increase cooperation. By allowing the child to choose how they take the medication, they may be more willing to comply.
D. Hide the medication in a large dish of ice cream: While hiding medication in food may be effective for some children, it can undermine trust if the child discovers the deception. Additionally, this method does not teach the child how to take medication independently and may not be feasible in all situations. Offering choices and involving the child in the decision-making process is a more respectful and effective approach.
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