A nurse is providing teaching for a client who has a new application of a long leg cast. Which of the following instructions should the nurse include?

Keep the casted leg flat for the first 24 hr.

Report any drainage from the casted leg.

Apply a heating pad to the casted leg.

Use a cotton-tip applicator to relieve itching inside the cast.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Keep the casted leg flat for the first 24 hr: The casted leg should not be kept flat for the first 24 hours. Elevating the leg above the heart is important to reduce swelling and promote circulation. Keeping it flat could increase swelling and discomfort.

B. Report any drainage from the casted leg: It is important to report any drainage from the cast, as it could indicate infection or complications, such as a wound underneath the cast. Drainage, especially if it is blood-tinged or excessive, requires prompt evaluation.

C. Apply a heating pad to the casted leg: Applying a heating pad is not recommended as it could increase swelling or cause burns. It is important to keep the cast cool and dry and avoid applying heat, which could affect the skin or underlying tissue.

D. Use a cotton-tip applicator to relieve itching inside the cast: Using a cotton-tip applicator can be harmful because it might push debris deeper into the cast, increasing the risk of infection or injury.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"A,B"},"E":{"answers":"A"}}

Explanation

Rationale:

Skin turgor: In DKA, dehydration is a common result due to fluid loss from excessive urination and hyperglycemia. Decreased skin turgor, or slight tenting, is an indicator of dehydration. HHS is characterized by severe hyperglycemia and profound dehydration, leading to significant fluid deficits and impaired skin turgor.
Blood glucose greater than expected reference range: Both DKA and HHS present with elevated blood glucose levels. The client's blood glucose level of 468 mg/dL is higher than the expected range. However, blood glucose levels tend to be much higher in HHS, sometimes exceeding 1000 mg/dL, while DKA usually ranges between 250–600 mg/dL.
Blood pH: A blood pH of 7.30 is low and indicative of acidosis, which is a hallmark of DKA. In DKA, the body produces ketones as a byproduct of fat metabolism, which causes the blood pH to drop, leading to metabolic acidosis. HHS typically does not cause significant acidosis, and pH is generally within normal limits.
Creatinine greater than expected reference range: Elevated creatinine levels suggest kidney impairment, which is common in DKA and HHS due to severe dehydration and osmotic diuresis. Dehydration significantly impairs renal perfusion and function, leading to elevated creatinine and BUN levels.
Urine ketones: Ketones form when the body starts breaking down fat for energy due to a lack of insulin, which is characteristic of DKA. In HHS, the body does not typically produce significant amounts of ketones, as some insulin is still present and inhibiting fat metabolism.

A. Initiate venous access with a 21-gauge needle. B. Obtain the client's first set of vital signs 1 hr after initiating the transfusion. C. Administer the unit of packed RBCs over 1 hr. D. Use Y tubing with 0.9% sodium chloride when administering the transfusion.

Correct Answer is D

Explanation

Rationale:

A. "Initiate venous access with a 21-gauge needle." For blood transfusions, it is recommended to use a larger gauge needle, 18-20 gauge, to allow for proper blood flow and reduce the risk of hemolysis. A 21-gauge needle is too small for optimal transfusion.

B. "Obtain the client's first set of vital signs 1 hr after initiating the transfusion." The first set of vital signs should be obtained immediately before starting the transfusion, and then monitored every 15 minutes to detect any early signs of a transfusion reaction.

C. "Administer the unit of packed RBCs over 1 hr." The unit of packed RBCs should be administered over 4 hours to reduce the risk of transfusion reactions and allow for optimal oxygen-carrying capacity. Infusing blood too quickly can cause complications such as volume overload or reactions.

D. "Use Y tubing with 0.9% sodium chloride when administering the transfusion." Y tubing is commonly used for blood transfusions to allow for the infusion of normal saline (0.9% sodium chloride) alongside the blood product. This helps maintain the flow of the transfusion and reduces the risk of clot formation while flushing the line.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is providing teaching for a client who has a new application of a long leg cast. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in the emergency department. Exhibits For each assessment finding, click to specify if the assessment finding is consistent with diabetic ketoacidosis (DKA) or hyperglycemic-hyperosmolar state (HHS). Each finding may support more than 1 disease process.

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"A,B"},"E":{"answers":"A"}}

Explanation

A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

A home health nurse is planning to use nonpharmacological pain relief measures for a client who has severe chronic back pain. Which of the following pain management guidelines should the nurse use?

A nurse is caring for a client in the emergency department. Exhibits The nurse is caring for the client in the ED. The nurse understands that the client is at risk of developing which of the following complications? Select all that apply.

A nurse is caring for a client who has pneumonia caused by Haemophilus influenzae type B. Which of the following types of isolation precautions should the nurse implement?

A nurse is providing discharge teaching to a client who has a permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching?

The nurse is reviewing the client's medical record. Exhibits A nurse is reviewing the client's diagnostic results and vital signs. Which of the following actions should the nurse take? Select all that apply.

A nurse is preparing an in-service presentation about the use of automated external defibrillators (AEDs). Which of the following instructions should the nurse include in the teaching?

Exhibits Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

The nurse is reviewing the client's medical record. Exhibits The nurse is reviewing the client's medical record. Which of the following findings indicates the client's condition has improved? Select all that apply.