A nurse is instructing a client on the maintenance of their cast. Which of the following instructions should be given to the client?

"Trim off the rough edges of the cast if it bothers you in order to promote comfort."

"You might feel tightness and pain with the cast and that is a normal feeling."

"You might feel itchy under the cast, and it is okay to scratch under the cast with a very slim tool."

"Once the cast is dry, you can shower if you cover it with a plastic covering"

Answer and Explanation

The Correct Answer is D

A. "Trim off the rough edges of the cast if it bothers you in order to promote comfort.": The rough edges should be addressed by the healthcare provider to prevent injury to the skin, as cutting the cast improperly could cause damage to the structure or harm the client.

B. "You might feel tightness and pain with the cast and that is a normal feeling.": Tightness and pain could indicate complications such as compartment syndrome, which requires immediate attention. The client should report any unusual or severe pain, and tightness.

C. "You might feel itchy under the cast, and it is okay to scratch under the cast with a very slim tool.": Scratching under the cast with any object can cause skin irritation, injury, or infection. Itching can be managed with prescribed methods, but inserting objects into the cast should be avoided.

D. "Once the cast is dry, you can shower if you cover it with a plastic covering.": After the cast is fully dry, the client can protect it from water by covering it with a plastic bag or other waterproof covering during showers to keep it dry and intact.

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Correct Answer is C

Explanation

A. Ensure the door to the client's room remains open: The door should be kept closed to minimize exposure to radiation. Keeping the door open increases the risk of radiation exposure to others in the area.

B. Wear sterile gloves during patient care: Sterile gloves are not required for care during internal radiation therapy unless there is direct contact with bodily fluids or radioactive materials. Standard precautions are sufficient.

C. Wear a lead apron when providing client care: A lead apron is recommended for healthcare workers to protect themselves from radiation exposure during internal radiation therapy. The lead apron absorbs radiation and helps reduce the risk of harmful exposure.

D. Place a dosimeter on the client's gown: The dosimeter is typically worn by healthcare workers to measure radiation exposure, not the client. The client would not wear a dosimeter in this situation.

A. Gently squeeze the tubing to remove excess drainage. B. Raise the drainage system to the client's chest level. C. Clamp the tubing to check for air leaks. D. Empty the collection chamber.

Correct Answer is C

Explanation

A. Gently squeeze the tubing to remove excess drainage: Squeezing the tubing is not recommended as it could cause injury or increase pressure within the system. The nurse should not manipulate the tubing in this way, as it does not address the continuous bubbling.
B. Raise the drainage system to the client's chest level: The drainage system should always be below the level of the client's chest to promote proper drainage. Raising the system to chest level could disrupt the drainage process and cause complications.
C. Clamp the tubing to check for air leaks: Continuous bubbling in the water seal chamber may indicate an air leak in the system. The nurse should clamp the tubing temporarily to isolate the source of the leak and check for any external leaks or loose connections.
D. Empty the collection chamber: The collection chamber should only be emptied when it is full. Continuous bubbling in the water seal chamber is more likely an indication of an air leak. The nurse should first assess for leaks before considering emptying the chamber.

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A nurse is instructing a client on the maintenance of their cast. Which of the following instructions should be given to the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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