A client is experiencing numbness and tingling distal to a new arm cast with no increase in pain. The nurse assesses that the client's fingers are pale, cool and swollen. What action does the nurse take next?

Correct Answer: B

Rationale: In this scenario, the correct action for the nurse to take next is to choose option B) Raise the arm above the level of the heart. The client is showing signs of impaired circulation distal to the cast, indicated by pale, cool, and swollen fingers. Elevating the arm above heart level helps reduce swelling and improve blood flow to the affected area. This position promotes venous return and can alleviate symptoms of compromised circulation. Option A) Removing the cast may not be necessary at this point as there is no increase in pain reported. Removing the cast without medical guidance can potentially worsen the client's condition. Option C) Applying heat to the affected hand is contraindicated in this situation as it can vasodilate blood vessels, potentially exacerbating swelling and compromising circulation further. Option D) Encouraging range of motion is not the priority in this case as the primary concern is addressing the compromised circulation. Range of motion exercises can be beneficial once the circulation issue has been resolved. From an educational perspective, understanding the rationale behind elevating the arm above heart level in cases of compromised circulation is crucial for nurses. It helps them make informed clinical decisions to promote optimal client outcomes and prevent complications related to impaired circulation.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Elementary school teacher, as this occupation involves a significant amount of repetitive hand movements such as writing on the board, grading papers, and using a computer, all of which can increase the risk of developing carpal tunnel syndrome due to the continuous strain on the wrist and hand muscles. Option B) Nursing assistant involves tasks that also require repetitive movements, but typically not to the same extent as an elementary school teacher, thus making it a less likely choice for increasing the risk of carpal tunnel syndrome. Option C) Assembly line worker is a physically demanding job that may involve repetitive motions, but carpal tunnel syndrome is more commonly associated with occupations that involve fine motor skills and prolonged use of the hands in specific positions, which is less common in assembly line work. Option D) Truck driver, while requiring long hours of driving, does not typically involve the same level of repetitive hand and wrist movements as the other options mentioned, making it less likely to increase the risk of carpal tunnel syndrome. Educationally, it's important for healthcare professionals to understand the specific occupational risks associated with certain professions to provide relevant and targeted education and preventive strategies to individuals at risk. By identifying occupations that pose a higher risk for conditions like carpal tunnel syndrome, nurses can tailor their community presentations to promote awareness and provide practical advice for prevention and early intervention.

Correct Answer: A

Rationale: The most appropriate intervention for reducing the risk for a friction and shear injury in an intubated and sedated geriatric client is option A, which is to use a mechanical lift to reposition the client every 2 hours. This intervention is crucial as it helps in redistributing the pressure on the client's body, thereby reducing the risk of pressure ulcers due to friction and shear forces. Repositioning the client with a mechanical lift ensures proper body alignment and minimizes the stress on vulnerable areas, such as bony prominences, which are prone to pressure injuries. Option B, elevating the client's head of the bed to 45 degrees, is not the most appropriate intervention for reducing friction and shear injuries in this scenario. While elevating the head of the bed may have other benefits such as improving ventilation, it does not directly address the risk of pressure injuries caused by friction and shear. Option C, postponing the daily bed bath, is also not the best choice as hygiene is important in preventing infections and maintaining the client's skin integrity. Regular hygiene practices should be maintained while implementing appropriate pressure injury prevention strategies. Option D, where the caregiver independently slides the client up in the bed, is not recommended as it can increase the risk of friction and shear injuries. Improper manual handling techniques can cause friction and shear forces on the client's skin, leading to pressure ulcers. In an educational context, understanding the importance of pressure injury prevention strategies is crucial for healthcare providers caring for vulnerable populations. Proper positioning and repositioning techniques, the use of assistive devices like mechanical lifts, and regular skin assessments are essential components of quality care to prevent pressure injuries in immobilized or sedated patients.

Correct Answer: A

Rationale: In this scenario, the correct action for the nurse to take first is option A) Collect a culture of the purulent fluid. This is crucial as the redness, swelling, and purulent drainage around the pins indicate a possible infection in the area of skeletal traction. Collecting a culture will help identify the specific microorganism causing the infection, which is essential for selecting the most effective antibiotic for treatment. Option B) Cleanse the skin around the pins is incorrect because while maintaining skin integrity is important, addressing the infection by identifying the causative organism takes precedence. Option C) Administer an antibiotic is premature without knowing the specific pathogen causing the infection, as the choice of antibiotic should be guided by culture and sensitivity results. Option D) Instruct the client to complete exercise of the affected extremity is inappropriate at this time as the priority is to address the infection to prevent further complications. Educationally, this question highlights the importance of prioritizing nursing actions based on the assessment findings and understanding the principles of infection control. It also emphasizes the significance of proper wound care, infection management, and the role of diagnostic testing in guiding treatment decisions. Nurses need to have a solid foundation in recognizing signs of infection and implementing appropriate interventions to ensure optimal patient outcomes.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Have client sit in a wheelchair as much as possible. This option increases the risk of pressure injuries because prolonged sitting can lead to pressure points on bony prominences, especially if the individual is unable to shift their weight or change positions frequently. This can result in decreased blood flow to the area, leading to tissue damage and the development of pressure injuries. Option A) Padding hard surfaces is actually a preventive measure that reduces the risk of pressure injuries by providing cushioning and reducing pressure on bony areas. Option C) Placing pillows between bony surfaces is also a recommended nursing intervention to prevent pressure injuries by reducing pressure and friction on vulnerable areas. Option D) Keeping the head of the bed at or less than 30 degrees is a measure to prevent aspiration in patients at risk of choking or aspiration pneumonia, and it is not directly related to the development of pressure injuries. Educationally, understanding the risk factors and preventive measures for pressure injuries is crucial for nurses caring for patients with limited mobility. It is essential to promote frequent repositioning, proper support surfaces, and pressure-relieving devices to mitigate the risk of pressure injuries and provide optimal care for patients at risk.