nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following actions is best for the nurse to take?

Perform a neurovascular assessment.

Provide reassurance to the client and parents.

Apply an ice pack to the casted leg.

Explain the discharge instructions to the client and parents.

Answer and Explanation

The Correct Answer is A

A. Perform a neurovascular assessment: This is the correct answer. After a cast is applied, it’s crucial to regularly assess the client’s neurovascular status (sensation, movement, temperature, color, and capillary refill) to ensure that the cast is not too tight and that circulation is not compromised.
B. Provide reassurance to the client and parents: While this is important, the immediate priority is to ensure the client’s physical well-being.
C. Apply an ice pack to the casted leg: This can help reduce swelling and pain, but it’s not the immediate priority. The nurse first needs to ensure that the cast is not compromising circulation or nerve function.
D. Explain the discharge instructions to the client and parents: This is typically done later, closer to the time of discharge. The immediate priority is to assess the client’s physical condition.

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Correct Answer is B

Explanation

A. Apex of the heart: While the apex of the heart is a common site to listen to the heart sounds, it’s not typically used to measure the heart rate in infants.
B. Brachial artery: This is the correct answer. The brachial artery, located on the inside of the upper arm, is commonly used to assess the heart rate in infants.
C. Carotid artery: The carotid artery, located on the neck, is commonly used to assess the heart rate in adults, but it’s not typically used in infants.
D. Radial artery: The radial artery, located on the wrist, is also commonly used to assess the heart rate in adults, but it’s not typically used in infants.

A. A client who has an ankle fracture reports a pain level increase from 3 to 5 after initial ambulation B. A client who has a burn injury to an estimated 5% his leg and is crying C. A client's blood pressure changes from 112/60 mm Hg to 90/54 mm Hg when standing D. A who is client 1 day postoperative and has a temperature of 37.5° C (99.5° F)

Correct Answer is C

Explanation

A. A client who has an ankle fracture reports a pain level increase from 3 to 5 after initial ambulation: While this is important to monitor, it is not unexpected after initial ambulation and does not need to be reported immediately.
B. A client who has a burn injury to an estimated 5% his leg and is crying: This is also important to monitor, but crying is a normal response to pain and does not need to be reported immediately.
C. A client’s blood pressure changes from 112/60 mm Hg to 90/54 mm Hg when standing: This is the correct answer. This significant drop in blood pressure could indicate orthostatic hypotension, which can lead to dizziness and falls, and should be reported immediately.
D. A client who is 1 day postoperative and has a temperature of 37.5° C (99.5° F): This is a normal body temperature and does not need to be reported immediately.

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nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following actions is best for the nurse to take?

Nursing Test Bank

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