Nokea
A client had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires immediate attention?
- A. Capillary refill of fingers on right hand is 3 seconds
- B. Skin warm to touch and normally colored
- C. Client reports prickling sensation in the right hand
- D. Slight swelling of fingers of right hand
Correct Answer: C
Rationale: A prickling sensation in the right hand is indicative of compartment syndrome, a serious condition that can lead to tissue damage and impaired circulation. Immediate attention is required to prevent complications. Capillary refill of 3 seconds, warm and normally colored skin, and slight swelling of fingers are expected findings after a closed reduction and casting. These findings do not typically indicate a critical issue and can be managed with routine monitoring.
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Why are subdural hemorrhages more common in the elderly?
- A. Increased anticoagulant use
- B. Increased risk of falls
- C. Brain atrophy
- D. Inconsistent care giving
Correct Answer: C
Rationale: Subdural hemorrhages are more common in the elderly due to cerebral atrophy resulting from the natural aging process. This atrophy can lead to the stretching of bridging veins, making them more fragile and prone to tearing even with minor trauma. While increased anticoagulant use and a higher risk of falls are common in the elderly, brain atrophy plays a more direct role in the increased incidence of subdural hemorrhages. Inconsistent caregiving, on the other hand, is not a direct cause of subdural hemorrhages but may impact the overall management and outcome of such cases.
A 3-year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should
- A. Expose the cast to air and turn the child frequently
- B. Use a heat lamp to reduce the drying time
- C. Handle the cast with the abductor bar
- D. Turn the child as little as possible
Correct Answer: A
Rationale: After applying a hip spica cast, it is important to facilitate drying by exposing the cast to air and turning the child frequently. This helps promote even drying and prevents complications such as skin breakdown. Using a heat lamp can cause burns and is not recommended. Handling the cast with the abductor bar does not aid in drying the cast. Turning the child as little as possible is incorrect as regular turning is crucial to prevent complications.
What is the primary nursing concern when caring for patients being treated with splints, casts, or traction?
- A. To assess for and prevent neurovascular complications or dysfunction
- B. To ensure adequate nutrition during the healing process
- C. To provide patient education for maintenance of splints, casts, or traction in the community
- D. To treat acute pain
Correct Answer: A
Rationale: The primary nursing concern when caring for patients with splints, casts, or traction is to assess for and prevent neurovascular complications or dysfunction. This is crucial to ensure adequate circulation and nerve function, preventing long-term complications such as ischemia or nerve damage. While adequate nutrition and patient education are important aspects of care, they are not the primary concern in this scenario. Acute pain management is important but is secondary to preventing neurovascular complications in patients treated with splints, casts, or traction.
What nursing action demonstrates the nurse understands the priority nursing diagnosis when caring for patients being treated with splints, casts, or traction?
- A. The nurse assesses extremity pulse, temperature, color, pain, and feeling every hour.
- B. The nurse orders meals with adequate protein and calcium for the patient.
- C. The nurse teaches the patient never to insert objects under a cast to scratch an itch.
- D. The nurse administers oral painkillers as ordered.
Correct Answer: A
Rationale: The correct answer is to assess extremity pulse, temperature, color, pain, and feeling every hour. This action aligns with the priority nursing diagnosis of Risk for Peripheral Neurovascular Dysfunction related to fractures. Monitoring these factors is crucial to detect any signs of compromised circulation or nerve function promptly. Option B is incorrect as it does not directly address the priority nursing diagnosis. Option C is important but does not directly relate to the neurovascular aspect. Option D, administering painkillers, is necessary but does not specifically address the priority nursing diagnosis of neurovascular dysfunction.
A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would:
- A. Instruct the client to maintain a regular diet the day prior to the examination
- B. Restrict the client's fluid intake 4 hours prior to the examination
- C. Administer a laxative to the client the evening before the examination
- D. Inform the client that only 1 x-ray of his abdomen is necessary
Correct Answer: C
Rationale: Administering a laxative to the client the evening before the examination is the correct action. Bowel prep is crucial for an Intravenous Pyelogram (IVP) as it helps in achieving better visualization of the bladder and ureters. Instructing the client to maintain a regular diet the day prior to the examination (Choice A) is not the appropriate preparation for an IVP. Restricting the client's fluid intake 4 hours prior to the examination (Choice B) is not necessary for this test. Informing the client that only 1 x-ray of his abdomen is necessary (Choice D) is not relevant to the preparation process for an IVP.