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 C
Explanation
A. A room with another nonsurgical client: Placing a client with active tuberculosis in a room with another nonsurgical client is not appropriate because it increases the risk of transmission to other patients. Tuberculosis is highly contagious, and isolation precautions are necessary to prevent the spread of the disease.
B. A room in the ICU: While isolation precautions are necessary for a client with active tuberculosis, placing the client in the intensive care unit (ICU) may not be necessary unless the client requires critical care. However, the priority is to provide a room that meets the requirements for airborne infection isolation, which may not necessarily be in the ICU.
C. A room with air exhaust directly to the outdoor environment: This is the correct choice. A room with air exhaust directly to the outdoor environment is essential for a client with active tuberculosis. Airborne infection isolation rooms (AIIRs) have negative air pressure and special ventilation systems that prevent the circulation of air from the room to other areas of the healthcare facility, reducing the risk of transmission to healthcare workers and other patients.
D. A room that is within view of the nursing station: While it may be convenient for the nursing staff to have the client's room within view of the nursing station for monitoring purposes, the priority for a client with active tuberculosis is to ensure that they are placed in a room with appropriate airborne infection isolation precautions, including proper ventilation, to minimize the risk of transmission to others.
Correct Answer is D
Explanation
A. The AP's ability to complete the task without assistance: While it's important for the AP to be able to complete the task independently, this is not the only consideration when delegating tasks. The nurse should also consider whether the AP has the necessary knowledge and skill to perform the task safely and effectively.
B. The AP's rapport with clients: Although the AP's rapport with clients is valuable in providing care, it is not directly related to the ability to perform a delegated task. The nurse should prioritize delegation based on the AP's competency and skill level rather than their interpersonal skills.
C. The AP’s ability to prioritize: While the AP's ability to prioritize tasks is important in providing efficient care, it is not specifically related to the nurse's consideration when delegating tasks. Delegation decisions should primarily be based on the AP's knowledge and skill to perform the task safely and effectively.
D. The AP has the knowledge and skill to perform the task: This is the most appropriate consideration when delegating tasks. Ensuring that the AP has the necessary knowledge and skill to perform the delegated task safely and effectively is essential for patient safety and quality care. The nurse should assess the AP's competency and provide appropriate supervision and guidance as needed.
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