A patient taking a combination of antineoplastic agents develops stomatitis. Nursing care should include actions to prevent which problem?

Answer is d. Monitor the capillary refill time in the toes on both feet. This is crucial for assessing circulation and ensuring that the cast is not impairing blood flow, which is a priority in cast care.

Choice A rationale:

Ensuring the appropriate care for a wet plaster cast is essential to prevent complications such as impaired circulation, discomfort, or skin breakdown. Keeping the cast covered with a lightweight blanket, as suggested in option A, may seem like a logical step to protect it from external elements and maintain warmth. However, covering a wet cast can actually retain moisture, which can slow the drying process. Moisture retention within the cast can lead to prolonged drying times, increasing the risk of complications such as skin maceration or discomfort for the patient. Therefore, while the intention behind covering the cast is to provide comfort, it may inadvertently prolong the drying process and contribute to potential complications.

Choice B rationale:

Maintaining increased humidity in the patient room, as mentioned in option B, might appear beneficial to aid in the drying process of the plaster cast. However, while humidity can influence the drying time of the cast, excessive humidity can have adverse effects on the integrity of the cast. High humidity levels can prolong the drying process by inhibiting the evaporation of moisture from the cast material. Additionally, increased humidity can compromise the structural integrity of the cast, potentially leading to weaknesses or deformities. Therefore, while it's important to consider environmental factors in cast care, maintaining excessively high humidity levels may not be advisable and could contribute to complications in the drying and integrity of the cast.

Choice C rationale:

Option C suggests using only the tips of the fingers when handling the wet cast. While it's crucial to handle a wet cast with care to avoid causing damage or deformities, limiting handling to just the fingertips may not provide adequate support or control. Plaster casts can be fragile when wet, and improper handling techniques may lead to misshaping or weakening of the cast structure. Additionally, relying solely on the fingertips for handling may increase the risk of inadvertently applying uneven pressure or causing accidental damage to the cast material. Therefore, while the intention behind this option is to promote gentle handling, it may not provide sufficient support or control to ensure the integrity of the wet cast.

Choice D rationale:

Monitoring the capillary refill time in the toes on both feet, as indicated in option D, is the most appropriate action for the nurse to take in this scenario. Capillary refill time is a valuable indicator of peripheral circulation and tissue perfusion. By assessing the capillary refill time in the toes, the nurse can evaluate the adequacy of blood flow to the extremities and detect any potential impairment caused by the plaster hip spica cast. Prolonged capillary refill time may suggest compromised circulation, which can lead to serious complications such as ischemia or tissue necrosis if left unaddressed. Therefore, regular monitoring of capillary refill time is essential for early detection of circulation problems and timely intervention to ensure patient safety and optimal outcomes.

In conclusion, while each option may seem plausible at first glance, careful consideration of the potential implications reveals that monitoring capillary refill time in the toes on both feet is the most appropriate action for the nurse to take when caring for a patient with a wet plaster hip spica cast. This proactive approach prioritizes patient safety by ensuring adequate circulation and minimizing the risk of complications associated with impaired blood flow. By adhering to evidence-based practice guidelines and maintaining vigilance in monitoring patient status, healthcare professionals can optimize outcomes and promote the effective healing and management of patients with plaster casts.

Remove all beverages from the patient's bedside.

Choice A rationale:

Giving the patient a laxative is inappropriate and unnecessary in the context of a ruptured appendix. The focus should be on preparing the patient for surgery and managing the acute condition.

Choice B rationale:

Administering ibuprofen should be avoided as it can mask symptoms and potentially worsen the patient's condition by masking signs of inflammation or infection. This delay in appropriate care could lead to complications.

Choice C rationale:

Removing all beverages from the patient's bedside is essential. NPO (nothing by mouth) status is typically maintained for patients with suspected appendicitis or other surgical conditions to prevent potential aspiration in case surgery is required.

Choice D rationale:

Providing a heating pad is contraindicated in cases of suspected appendicitis or any acute abdominal condition. Heat can worsen inflammation and potentially cause the appendix to rupture, leading to more severe complications.