A client sustained a crushing injury to his right arm during a car accident. He arrives to the emergency room complaining of numbness in his right hand. He has no other injuries. What should the nurse do first?

Correct Answer: A

Rationale: The rationale for the correct answer and incorrect choices in this scenario is as follows: **Assess the right radial pulse (Correct Answer):** A crushing injury to the arm can lead to **compartment syndrome**, vascular damage, or nerve compression, all of which can compromise circulation and sensation. Numbness in the hand suggests possible **neurovascular impairment**, making immediate assessment of the radial pulse critical. The radial pulse is the most direct way to evaluate blood flow to the affected limb. If the pulse is weak, absent, or asymmetrical compared to the other arm, it indicates **ischemia** or **vascular injury**, requiring urgent intervention (e.g., surgical evaluation or compartment pressure measurement). Additionally, a diminished pulse alongside numbness supports the possibility of **nerve compression secondary to swelling or hematoma**. Thus, assessing circulation first ensures timely detection of life- or limb-threatening complications before proceeding with other interventions. **Call the provider (Incorrect Choice):** While notifying the provider is necessary, it should not be the *first* action without initial assessment data. The nurse must first **gather objective findings** (e.g., pulse strength, capillary refill, motor function) to provide the provider with a complete clinical picture. Calling without assessment risks delays in critical information, potentially leading to miscommunication or inadequate urgency in the provider’s response. For example, if the radial pulse is absent, the nurse can immediately escalate the situation as an emergency; if present, they may instead report stable findings with ongoing monitoring. **Administer pain medication (Incorrect Choice):** Pain management is important but **not the priority** in this case. Numbness, rather than pain, is the primary symptom, signaling potential **neurovascular compromise** rather than just tissue damage. Administering analgesics (especially opioids) could mask worsening symptoms (e.g., increasing pain unrelieved by medication, a red flag for compartment syndrome). Additionally, analgesics do not address the underlying cause of numbness, which could escalate to permanent damage if circulation is not restored promptly. Pain relief should follow *after* ensuring perfusion and nerve function are intact. **Assess the right pedal pulse (Incorrect Choice):** The pedal pulse is irrelevant in this context because the injury is localized to the **arm**. Assessing a lower extremity pulse would not provide information about vascular integrity in the affected limb. While systemic circulation checks (e.g., blood pressure) are part of trauma assessments, the focus here must be on the **right arm’s neurovascular status**. A pedal pulse assessment delays critical evaluation of the injury site and could result in missing signs of **compartment syndrome or arterial occlusion** specific to the arm. In summary, the correct sequence is to **first assess the radial pulse** to determine circulatory integrity, then proceed with provider notification or interventions based on findings. The incorrect choices either delay essential assessment, address non-urgent needs, or focus on unrelated systems, potentially compromising patient outcomes.

Correct Answer: C

Rationale: **Rationale:** **Choice C (Tinnitus) is correct** because tinnitus—a ringing, buzzing, or hissing sound in the ears—is a common symptom of hearing loss. It often results from damage to the hair cells in the cochlea or other auditory pathways, which can occur due to noise exposure, aging (presbycusis), or medical conditions. Tinnitus is frequently associated with sensorineural hearing loss, as the brain may compensate for reduced auditory input by generating phantom sounds. While tinnitus can occur independently, its presence alongside other symptoms strongly suggests hearing impairment. **Choice A (Presence of cerumen) is incorrect** because earwax (cerumen) is a normal bodily secretion that protects the ear canal. While excessive cerumen can cause temporary conductive hearing loss by blocking sound waves, its mere presence is not a definitive sign of hearing loss. Many individuals have cerumen without any auditory issues, and the problem is easily resolved with proper ear hygiene or medical removal. **Choice B (Presence of cerumen) is repeated and thus redundant**. It is the same as Choice A, and the rationale for its incorrectness remains identical. Redundant options in a question are typically errors and should not be considered valid distinct choices. **Choice D (Frequent asking of others to repeat statements) is incorrect** in this context because while it is a behavioral sign of hearing difficulty, the question specifies "signs of hearing loss," which typically refer to physiological or sensory indicators (e.g., tinnitus). Behavioral cues like asking for repetitions are secondary manifestations rather than direct signs. However, in clinical practice, this would still be relevant for diagnosing hearing impairment—just not the best fit for this question’s phrasing. The focus on **tinnitus (C)** as the correct answer highlights a primary sensory symptom directly linked to hearing loss mechanisms, whereas the other options either describe normal physiology (cerumen) or indirect behavioral effects (asking for repetitions). The repetition of Choice B further invalidates it as a distinct option. Understanding the distinction between direct symptoms and secondary effects is critical for accurately identifying hearing loss.

Correct Answer: C

Rationale: Immobility significantly increases the risk of pressure injuries (pressure ulcers) due to prolonged pressure on bony prominences, reduced blood flow, and potential shear forces from sliding or improper repositioning. The skin integrity of an immobile client must be inspected frequently—ideally every 2 hours—because early signs of injury (e.g., erythema, blisters, or tissue breakdown) require immediate intervention to prevent progression to severe wounds. Pressure injuries can develop rapidly (within hours) and lead to infections, prolonged hospitalization, or systemic complications. This makes skin inspection the **priority** assessment, as it addresses the most immediate and preventable threat to the client’s well-being. **Why other options are incorrect:** - **A: Palpate for edema** While edema assessment is important (e.g., for detecting DVT or fluid retention), it is not the **priority** for an immobile client. Edema may develop over time and is less immediately life-threatening than skin breakdown. Additionally, edema alone does not guide urgent interventions unless paired with other symptoms (e.g., pain or asymmetry suggesting thrombosis). - **B: Auscultate for bowel sounds** Immobility can slow gastrointestinal motility (leading to constipation or ileus), but bowel sounds are not the **first** priority. Bowel dysfunction typically develops over days and is not as immediately harmful as skin compromise. Monitoring bowel function is important but secondary to preventing pressure injuries. - **D: Auscultation of lung sounds** While immobility increases the risk of atelectasis or pneumonia due to shallow breathing, lung sounds are not the **priority** in the initial assessment. Respiratory complications usually manifest later (e.g., after 48–72 hours of immobility). Skin inspection takes precedence because it can prevent irreversible damage with early detection. In summary, **C** is correct because skin inspection directly addresses the most urgent and preventable complication of immobility (pressure injuries), while the other assessments are important but secondary in the immediate context. The rationale aligns with nursing priorities: preventing harm that is both rapid in onset and high in severity.

Correct Answer: D

Rationale: Administering eye drops correctly is critical to ensuring medication efficacy and preventing contamination or injury. The correct technique involves strict hygiene and avoiding direct contact between the dropper and the eye. **Why D is correct (the action needing further education):** Touching the dropper to the eye introduces a high risk of contamination. The dropper tip can pick up bacteria or debris from the eye, eyelashes, or surrounding skin, which may then contaminate the entire bottle of medication. Additionally, physical contact can cause microabrasions to the cornea or lead to accidental injury if the patient moves suddenly. Proper technique requires holding the dropper slightly above the eye (about 1-2 cm) to allow the drop to fall into the conjunctival sac without contact. **Why A is incorrect (acceptable action):** Setting the cap down in a non-contaminated manner (e.g., placing it on a clean tissue or holding it with the inner side facing upward) prevents exposure to dirt or microbes. Since the cap must be removed to administer drops, ensuring it remains clean is part of proper sterile technique. This action does not require correction. **Why B is incorrect (proper technique):** Instilling drops directly into the conjunctival sac (the pocket between the lower eyelid and eyeball) ensures optimal absorption and minimizes spillage. This area is less sensitive than the cornea, reducing discomfort. Dropping medication onto the cornea directly can cause irritation or reflexive blinking, leading to wasted medication. The client’s action here is correct. **Why C is incorrect (essential step):** Handwashing before handling eye drops is a fundamental infection control measure. Pathogens from unwashed hands can transfer to the eye or dropper, increasing the risk of infection (e.g., conjunctivitis). This step is non-negotiable in eye care and does not indicate a need for further teaching. **Key Takeaways for Proper Eye Drop Administration:** - Avoid dropper-to-eye contact to prevent contamination and injury. - Target the conjunctival sac for comfortable and effective delivery. - Maintain sterility by washing hands and handling the cap carefully. - Never touch the tip of the dropper to any surface, including the eye. Missteps like touching the dropper to the eye (D) compromise both safety and sterility, making it the clear indicator for additional client education. The other options (A, B, C) reflect correct practices that align with standard protocols for ophthalmic medication administration.

Correct Answer: D

Rationale: The correct answer is D because sudden increases in drainage from a cast are **never** expected and indicate a potential complication, such as infection or bleeding. A new cast may have minimal moisture initially from the casting material, but any sudden or significant increase in discharge is abnormal and requires immediate medical evaluation. This would suggest wound deterioration or infection beneath the cast, which could compromise healing and require intervention. **Why the other options are incorrect:** - **A (Use a sling to alleviate fatigue):** This is correct teaching. A sling helps support the arm, reducing muscle strain and discomfort, especially in the early stages of healing. It prevents excessive movement that could disrupt the cast or underlying injury. While it does not replace elevation for swelling, it is a valid recommendation for comfort and stability. - **B (Elevate the arm above the heart to reduce swelling):** This is appropriate post-cast care. Elevation minimizes edema by promoting venous return and reducing fluid accumulation in the injured area. Persistent swelling can cause pressure under the cast, leading to impaired circulation or compartment syndrome, so this instruction is essential. - **C (Report 'hot spots' felt under the cast):** This is critical teaching. A localized burning or "hot spot" may indicate pressure ulcers, infection, or tissue necrosis developing beneath the cast. Early reporting allows for timely assessment and cast adjustment to prevent further tissue damage. Ignoring this symptom could lead to serious complications. In contrast, **D** is dangerously incorrect because drainage should decrease over time, not increase. New drainage—especially if purulent, bloody, or foul-smelling—signals an active problem. The nurse must educate the client to recognize abnormal signs and seek care rather than dismissing them as expected. Proper monitoring prevents avoidable complications like osteomyelitis or delayed healing. Understanding these distinctions ensures safe post-cast management.