A nurse is caring for an adolescent following the application of a plaster cast for a fractured right tibia.
Which of the following actions should the nurse take?
Discourage the client from ambulating.
Keep the client's leg in a dependent position.
Use a hair dryer on a hot setting to dry the cast.
Perform a neurovascular check of the lower extremities.
The Correct Answer is D
Choice A rationale
Discouraging the client from ambulating is not necessary. In fact, early ambulation is often encouraged to promote circulation and prevent complications, depending on the fracture
type and treatment plan.
Choice B rationale
Keeping the client's leg in a dependent position is not recommended as it can increase swelling and pain. Elevating the leg is typically advised to reduce swelling.
Choice C rationale
Using a hair dryer on a hot setting to dry the cast is unsafe as it can cause burns and damage the cast. It's better to allow the cast to dry naturally and follow the healthcare provider's
instructions.
Choice D rationale
Performing a neurovascular check of the lower extremities is crucial to assess circulation, sensation, and movement. This helps in identifying any complications such as impaired
blood flow or nerve damage.
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Correct Answer is D
Explanation
Choice A rationale
Threatening a shot can cause fear and anxiety, potentially making the child more resistant to taking medication in the future.
Choice B rationale
Hiding medication in food can lead to mistrust if the child discovers it, and it's not a sustainable long-term solution.
Choice C rationale
Telling the child the medicine tastes like candy is misleading and can lead to distrust. It's important to be honest while finding practical solutions.
Choice D rationale
Offering an ice pop prior can numb the taste buds, making the medication more palatable without deceit, and can build positive associations with taking medication.
Correct Answer is B
Explanation
Choice A rationale
Headache could indicate various conditions but is not immediately life-threatening post-surgery. It may be due to medication or anesthesia but is not the priority.
Choice B rationale
Altered level of consciousness (LOC) is a critical finding. It may indicate complications such as hemorrhage, fat embolism, or hypoxia, which require urgent assessment and intervention.
Choice C rationale
Muscle spasms can be a common symptom post-surgery due to pain or positioning. While they need management, they do not take precedence over LOC changes.
Choice D rationale
An oral temperature of 37.7°C is slightly elevated but not alarming. It may be due to the body's normal inflammatory response post-surgery.