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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Free Nursing Study Resources

Correct Answer is ["B","E"]

Explanation

A. Place a tongue blade at the bedside: Inserting an object into the mouth during a seizure can lead to airway obstruction, dental injury, or harm to the client. The focus should be on ensuring the client’s safety and airway clearance without inserting any objects.

B. Dim the overhead lights: Dim lighting can help reduce external stimuli that might trigger a seizure. Bright or harsh lights can sometimes exacerbate seizures, so it’s important to create a calm environment that helps prevent further stimulation or agitation.

C. Assist the client to ambulate every 4 hr: Ambulation is not a priority during a seizure or in the immediate post-seizure period. The client’s safety should be ensured by limiting activities that could result in injury, such as walking, especially if they are at risk for more seizures.

D. Apply a warming blanket: Applying a warming blanket is not recommended, especially in the presence of meningitis, as it can increase the risk of hyperthermia. Meningitis can already cause fever, and adding heat may worsen the condition.

E. Have suction equipment at the bedside: Suction equipment should always be available for clients experiencing seizures. This ensures that any secretions or vomit can be cleared quickly to maintain a clear airway, which is essential during and after a seizure.

A. Offer oral fluids every 4 hr. B. Monitor the client's hemoglobin level. C. Check urinary output status every 4 hr. D. Administer furosemide IV.

Correct Answer is C

Explanation

A. Offer oral fluids every 4 hr: Offering oral fluids every 4 hours may not be frequent enough for a client with dehydration. The nurse should encourage the client to drink fluids more regularly (e.g., every 1-2 hours) to help prevent further dehydration.

B. Monitor the client's hemoglobin level: Monitoring the hemoglobin level is not a priority intervention for managing dehydration. The focus should be on fluid replacement and monitoring indicators of dehydration, such as urine output.

C. Check urinary output status every 4 hr: Monitoring urinary output regularly is crucial for assessing hydration status. Dehydration often leads to reduced urine output, and it is important to check for changes in output to adjust fluid intake and assess the effectiveness of interventions.

D. Administer furosemide IV: Furosemide is a diuretic, which increases urine output. Administering it to a client who is dehydrated would worsen their dehydration and is contraindicated. The focus should be on rehydration, not on further increasing fluid loss.

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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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Correct Answer is ["B","E"]

Explanation

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Correct Answer is C

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