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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Clear the respiratory tract: This is the correct action. Clearing the newborn's respiratory tract is the priority immediately after delivery to ensure adequate breathing. The nurse should suction the mouth and nose with a bulb syringe to remove any mucus or amniotic fluid and facilitate effective respiration.
B. Cut the umbilical cord: Cutting the umbilical cord is an important step in newborn care, but it is typically done after ensuring the newborn's immediate respiratory needs are met. The priority immediately after delivery is to establish effective breathing.
C. Stimulate the infant to cry: While stimulating the infant to cry can help clear the airways and establish effective breathing, it should be done concurrently with clearing the respiratory tract. Therefore, clearing the respiratory tract takes precedence over stimulating the infant to cry.
D. Dry the infant off and cover the head: Drying the infant and covering the head are important steps in newborn care to prevent heat loss and maintain thermal regulation. However, these actions can be done after ensuring the newborn's respiratory tract is clear and breathing is established.

A. Administer an analgesic PO B. Administer a local anesthetic C. Request a prescription for placement of a central venous access device D. Remove the catheter and insert another to a different size

Correct Answer is B

Explanation

A. Administer an analgesic PO: Administering an analgesic by mouth may not provide immediate relief for the pain at the insertion site of the IV catheter. Oral medications typically take time to be absorbed and reach therapeutic levels in the bloodstream, which may delay pain relief. Additionally, oral analgesics are not specifically targeted to the site of pain and may not adequately address localized discomfort associated with IV insertion.
B. Administer a local anesthetic: Administering a local anesthetic, such as lidocaine, is the most appropriate action to alleviate pain at the insertion site of the IV catheter. Local anesthetics block nerve impulses in the area where they are applied, temporarily numbing the site and providing rapid pain relief. The nurse can apply a topical local anesthetic cream or spray directly to the skin around the insertion site or infiltrate lidocaine into the subcutaneous tissue near the catheter insertion site to minimize discomfort for the client.
C. Request a prescription for placement of a central venous access device: Requesting a prescription for a central venous access device, such as a central venous catheter or peripherally inserted central catheter (PICC), is not indicated solely based on the client's report of pain at the insertion site of the IV catheter. Central venous access devices are typically reserved for clients requiring long-term intravenous therapy, frequent blood draws, or administration of vesicant or irritating medications. The decision to insert a central venous access device should be based on the client's specific clinical needs and the assessment of venous access options by the healthcare provider.
D. Remove the catheter and insert another of a different size: Removing the IV catheter and inserting another of a different size solely due to pain at the insertion site may not be necessary and could cause additional discomfort and trauma to the client. The nurse should assess the insertion site for signs of complications, such as infiltration, phlebitis, or infection, before considering catheter removal and replacement. If the IV catheter is appropriately positioned and functioning well, the nurse should focus on managing the client's pain at the current insertion site using appropriate interventions, such as administering a local anesthetic, rather than immediately removing the catheter.

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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?

Nursing Test Bank

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