A nurse is planning care for a client who has a radial fracture and a newly placed short arm cast on the left arm. Which of the following findings is the nurse's priority?

The client requires assistance with getting dressed.

The client reports numbness of the fingers of the left hand.

The client reports itching of the left arm.

The client has a pillow under their left arm.

Answer and Explanation

The Correct Answer is B

Choice A reason: While requiring assistance with getting dressed is an important consideration in care planning, it is not the most immediate priority. The nurse should ensure that the client's basic needs are met, but this does not represent an acute medical concern.

Choice B reason: The client reporting numbness of the fingers of the left hand is the most urgent priority. Numbness can indicate neurovascular compromise or increased pressure within the cast, which could lead to further injury or complications such as compartment syndrome. Immediate assessment and intervention are required to prevent permanent damage.

Choice C reason: Itching of the left arm under the cast is a common complaint and can be uncomfortable for the client. However, it is not a priority over potential neurovascular compromise. The nurse can provide education on how to safely alleviate itching without compromising the integrity of the cast.

Choice D reason: Having a pillow under the left arm is part of proper positioning to reduce swelling and provide comfort. While it is a part of good nursing care, it is not a priority over signs of neurovascular compromise.

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Correct Answer is B

Explanation

Choice A reason: Changing the ostomy pouch daily is not typically necessary. Most pouches can be worn comfortably for several days before needing to be changed. Frequent changes are not only unnecessary but can also irritate the skin around the stoma.

Choice B reason: Emptying the ostomy pouch when it is 2/3 full is recommended to prevent leaks and overfilling, which can lead to discomfort and potential skin irritation. It is important to monitor the fullness of the pouch and empty it regularly to maintain hygiene and comfort.

Choice C reason: Trimming the opening of the ostomy seal to be 1/2 inch wider than the stoma is incorrect. The opening should be cut to match the size of the stoma to ensure a snug fit that prevents leakage and protects the skin around the stoma.

Choice D reason: Applying lotion to the peristomal skin when changing the ostomy pouch is not advised. Lotions or creams can interfere with the adhesive of the ostomy appliance and should be avoided. The peristomal skin should be clean and dry to ensure proper adhesion of the ostomy appliance.

A. Instruct the client to expect tingling in their extremities. B. Measure blood glucose every 2 hours. C. Limit the client's fluid intake. D. Instruct the client to lie flat.

Correct Answer is D

Explanation

Choice A reason: Instructing the client to expect tingling in their extremities is not a standard post-lumbar puncture care instruction. Tingling may be a sign of nerve irritation or damage, which is not an expected outcome and should be reported if it occurs.

Choice B reason: Measuring blood glucose every 2 hours is not related to post-lumbar puncture care unless the client has a specific condition that requires such monitoring. Post-lumbar puncture care focuses on preventing complications such as headaches and monitoring for signs of infection or bleeding.

Choice C reason: Limiting the client's fluid intake is not advised following a lumbar puncture. In fact, increasing fluid intake can help prevent the occurrence of post-lumbar puncture headaches, which are a common complication. Adequate hydration helps replenish cerebrospinal fluid and reduce headache severity.

Choice D reason: Instructing the client to lie flat is the correct action. After a lumbar puncture, it is recommended that the client lies flat for several hours to prevent the leakage of cerebrospinal fluid from the puncture site, which can lead to a spinal headache. Lying flat helps maintain normal cerebrospinal fluid pressure and reduces the risk of headache.

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A nurse is planning care for a client who has a radial fracture and a newly placed short arm cast on the left arm. Which of the following findings is the nurse's priority?

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