Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has a cast in place for a fractured tibia. Which of the following nursing actions is the priority immediately after the provider has applied the cast?
A. Performing range of motion
Performing range of motion: This should not be done immediately after applying the cast, as it may compromise the integrity of the cast. Range of motion exercises should be initiated once the cast has fully set and as directed by the healthcare provider.
B. Checking capillary refill distal to the cast
Checking capillary refill distal to the cast: This is the priority after applying the cast. It assesses blood flow to the extremity below the cast. Impaired circulation could lead to serious complications, so it's crucial to monitor capillary refill promptly.
C. Teaching the client about cast care
Teaching the client about cast care: While providing education about cast care is important, it is not the immediate priority. Ensuring proper circulation is more critical in the initial moments after applying the cast.
D. Managing pain
Managing pain: While pain management is important, it is not the immediate priority after applying the cast. Ensuring proper circulation and assessing for any signs of impairment take precedence. Pain management can be addressed once circulation is confirmed to be adequate.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Med Surg Proctored Exam 6. Take the full exam now
Full Explanation
A. Performing range of motion: This should not be done immediately after applying the cast, as it may compromise the integrity of the cast. Range of motion exercises should be initiated once the cast has fully set and as directed by the healthcare provider.
B. Checking capillary refill distal to the cast: This is the priority after applying the cast. It assesses blood flow to the extremity below the cast. Impaired circulation could lead to serious complications, so it's crucial to monitor capillary refill promptly.
C. Teaching the client about cast care: While providing education about cast care is important, it is not the immediate priority. Ensuring proper circulation is more critical in the initial moments after applying the cast.
D. Managing pain: While pain management is important, it is not the immediate priority after applying the cast. Ensuring proper circulation and assessing for any signs of impairment take precedence. Pain management can be addressed once circulation is confirmed to be adequate.
Similar Questions
A nurse is caring for a client who has a severe gangrenous infection of the right lower extremity. The nurse should plan preoperative teaching based on the possibility of which of the following amputation procedures?
A. "Your pain will gradually become less severe."
"Your pain will gradually become less severe." This statement is accurate and provides realistic expectations for the client. After an amputation, there will be initial post operative pain, but it should gradually decrease over time.
B. The pain will disappear soon."
"The pain will disappear soon." This statement is not accurate. While the pain will eventually decrease, it may not completely disappear immediately after the procedure.
C. "it's likely that you will have only a tingling sensation."
"It's likely that you will have only a tingling sensation." This statement is not accurate. While some clients may experience tingling sensations, it is not the only sensation they may feel, and this statement does not cover the full range of possible experiences.
D. "Phantom pain is mostly psychological.
"Phantom pain is mostly psychological." This statement is not accurate. Phantom pain is a real sensation that some individuals experience after an amputation. It is believed to be related to nerve endings that continue to send signals to the brain even though the limb is no longer present. It is not purely psychological.
Full Explanation
A. "Your pain will gradually become less severe." This statement is accurate and provides realistic expectations for the client. After an amputation, there will be initial post operative pain, but it should gradually decrease over time.
B. "The pain will disappear soon." This statement is not accurate. While the pain will eventually decrease, it may not completely disappear immediately after the procedure.
C. "It's likely that you will have only a tingling sensation." This statement is not accurate. While some clients may experience tingling sensations, it is not the only sensation they may feel, and this statement does not cover the full range of possible experiences.
D. "Phantom pain is mostly psychological." This statement is not accurate. Phantom pain is a real sensation that some individuals experience after an amputation. It is believed to be related to nerve endings that continue to send signals to the brain even though the limb is no longer present. It is not purely psychological.
A nurse is preparing a client who is postoperative following a below-the knee amputation for a leg prosthesis fitting. Which of the following actions should the nurse take?
A. Remove the elastic bandage and re-wrap the stump once per day.
Remove the elastic bandage and re-wrap the stump once per day: This is not recommended. The elastic bandage provides support and helps reduce swelling. It should only be removed and re-wrapped as directed by the healthcare provider.
B. Secure the elastic bandage to the lowest joint.
Secure the elastic bandage to the lowest joint: The bandage should be secure, but it should not be tied too tightly or secured directly over a joint. This could restrict blood flow and cause discomfort.
C. Wrap the stump with an elastic bandage in a figure-eight configuration.
Wrap the stump with an elastic bandage in a figure-eight configuration: This is the correct action. A figure-eight configuration helps distribute pressure evenly, providing support and reducing the risk of edema and complications.
D. Perform passive range-of-motion exercises once daily.
Perform passive range-of-motion exercises once daily: Range-of-motion exercises are important, but they should be performed within the parameters set by the healthcare provider. They should not be performed only once daily, and it's essential to avoid overexertion or straining the residual limb.
Full Explanation
A. Remove the elastic bandage and re-wrap the stump once per day: This is not recommended. The elastic bandage provides support and helps reduce swelling. It should only be removed and re-wrapped as directed by the healthcare provider.
B. Secure the elastic bandage to the lowest joint: The bandage should be secure, but it should not be tied too tightly or secured directly over a joint. This could restrict blood flow and cause discomfort.
C. Wrap the stump with an elastic bandage in a figure-eight configuration: This is the correct action. A figure-eight configuration helps distribute pressure evenly, providing support and reducing the risk of edema and complications.
D. Perform passive range-of-motion exercises once daily: Range-of-motion exercises are important, but they should be performed within the parameters set by the healthcare provider. They should not be performed only once daily, and it's essential to avoid overexertion or straining the residual limb.
A nurse is completing discharge teaching with a client following arthroscopic knee surgery. Which of the following instructions should the nurse include in the teaching?
A. Remain on bedrest for the first 24 hr.
Remain on bedrest for the first 24 hr.: This is not recommended after arthroscopic knee surgery. Early mobilization and ambulation are encouraged to prevent complications such as blood clots and promote healing.
B. Apply ice to the affected area.
Apply ice to the affected area: This is an important instruction. Applying ice can help reduce swelling and pain after surgery. It's typically recommended for the first 24-48 hours.
C. Begin active range of motion.
Begin active range of motion: While range of motion exercises are important, they should be initiated as directed by the healthcare provider, and they should be done gently to avoid straining the surgical site.
D. Keep the leg in a dependent position.
Keep the leg in a dependent position: This is not recommended. Elevating the leg can help reduce swelling and promote circulation. Keeping the leg in a dependent position could exacerbate swelling and discomfort.
Full Explanation
A. Remain on bedrest for the first 24 hr.: This is not recommended after arthroscopic knee surgery. Early mobilization and ambulation are encouraged to prevent complications such as blood clots and promote healing.
B. Apply ice to the affected area: This is an important instruction. Applying ice can help reduce swelling and pain after surgery. It's typically recommended for the first 24-48 hours.
C. Begin active range of motion: While range of motion exercises are important, they should be initiated as directed by the healthcare provider, and they should be done gently to avoid straining the surgical site.
D. Keep the leg in a dependent position: This is not recommended. Elevating the leg can help reduce swelling and promote circulation. Keeping the leg in a dependent position could exacerbate swelling and discomfort.