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 correct action is to assess the right radial pulse first because the client's symptoms (numbness in the right hand after a crushing injury to the right arm) suggest potential vascular compromise or compartment syndrome. A crushing injury can lead to swelling, increased pressure within the fascial compartments, and subsequent compression of nerves and blood vessels. The radial pulse is a direct indicator of arterial perfusion to the hand. If the pulse is weak or absent, this signals impaired blood flow, which is a medical emergency requiring immediate intervention to prevent tissue necrosis or permanent damage. Assessing the pulse provides critical data to guide further actions, such as notifying the provider or preparing for possible surgical intervention (e.g., fasciotomy). **Why other options are incorrect:** - **B: Call the provider** – While notifying the provider is important, it should occur *after* gathering initial assessment data (e.g., pulse, capillary refill, pain characteristics). Without assessing the radial pulse first, the nurse lacks objective information to communicate to the provider, which could delay appropriate treatment. The provider will need specific findings (e.g., pulse quality, signs of ischemia) to make clinical decisions. - **C: Administer pain medication** – Pain management is a priority in trauma, but numbness (not pain) is the primary symptom here, indicating possible neurovascular compromise. Administering analgesics without first assessing circulation could mask worsening symptoms (e.g., unrelenting pain from ischemia) and delay lifesaving interventions. Pain relief should follow the evaluation of vascular and neurological status. - **D: Assess the right pedal pulse** – A pedal pulse evaluates circulation to the foot, which is irrelevant in this scenario. The injury is localized to the arm, and the symptom (hand numbness) points to radial artery or peripheral nerve involvement in the upper extremity. Checking a pedal pulse wastes time and does not address the immediate concern. In summary, the radial pulse assessment is the most urgent action because it directly evaluates perfusion to the affected limb, aligns with the client's symptoms, and informs subsequent interventions. The incorrect choices either delay critical assessment, address unrelated systems, or prioritize less urgent interventions without proper clinical justification.

Correct Answer: C

Rationale: **Rationale:** **C: Tinnitus** is a correct answer because it is a well-documented symptom of hearing loss. Tinnitus refers to the perception of ringing, buzzing, or other noises in the ears when no external sound is present. It often occurs due to damage to the hair cells in the cochlea, which are responsible for transmitting sound signals to the brain. This damage can result from prolonged exposure to loud noises, aging (presbycusis), or other underlying health conditions. Tinnitus is not a disease itself but a symptom of an auditory system malfunction, making it a strong indicator of hearing loss. Patients with tinnitus frequently report difficulty hearing external sounds clearly, further supporting its association with hearing impairment. **A: Answering questions correctly** is incorrect because this behavior does not indicate hearing loss. In fact, individuals with hearing loss may often answer questions incorrectly or inappropriately due to mishearing or not hearing the question at all. Those with mild to moderate hearing loss might rely on contextual clues or lip-reading to respond, but this is not a reliable sign of normal hearing. The ability to answer questions correctly is more indicative of cognitive function or comprehension rather than auditory health. Therefore, this option does not align with the signs of hearing loss. **B: Presence of cerumen** is incorrect because while excessive earwax (cerumen) can cause temporary conductive hearing loss by blocking the ear canal, it is not a definitive sign of hearing loss itself. Many people have cerumen buildup without experiencing hearing impairment, and the condition is easily treatable with proper ear cleaning. Hearing loss due to cerumen is usually reversible once the blockage is removed, unlike sensorineural hearing loss, which is permanent. Thus, the mere presence of cerumen is not a reliable or standalone indicator of hearing loss. **D: Frequent asking of others to repeat statements** is actually a correct sign of hearing loss, though it was not marked as such in the provided "correct answer." This behavior is a classic red flag for hearing impairment, as individuals struggling to hear clearly often ask others to repeat themselves. It suggests difficulty perceiving speech, especially in noisy environments or when speaking softly. This symptom is particularly common in age-related or noise-induced hearing loss, where high-frequency sounds (like consonants) become harder to distinguish. However, since the question’s designated correct answer was only C, this explanation highlights a discrepancy in the provided answer key. In summary, tinnitus (C) is a correct sign of hearing loss due to its direct link to auditory system damage, while answering questions correctly (A) is irrelevant, and cerumen (B) is only indirectly related. The exclusion of frequent requests for repetition (D) as a correct answer is inconsistent with clinical evidence, as it is a primary behavioral sign of hearing difficulty.

Correct Answer: C

Rationale: Inspecting the skin for injury is the priority assessment for an immobile client because prolonged immobility significantly increases the risk of pressure injuries (formerly called pressure ulcers or bedsores). These injuries develop due to unrelieved pressure on bony prominences (e.g., sacrum, heels, elbows), which compromises blood flow to the tissues, leading to ischemia, necrosis, and potential infection. Early identification of skin breakdown—such as non-blanchable erythema, blisters, or open wounds—allows for timely interventions like repositioning, pressure-relieving devices, and wound care, preventing further complications. Immobility also reduces sensory feedback, meaning the client may not feel discomfort, making visual inspection critical. Palpating for edema (A) is important but not the priority. Edema can indicate fluid retention or circulatory issues, but it is a secondary concern compared to the immediate risk of skin breakdown. While edema may exacerbate pressure injuries, it does not pose as acute a threat as undetected tissue damage. Similarly, auscultating for bowel sounds (B) assesses gastrointestinal motility, which can be impaired in immobile clients (e.g., due to slowed peristalsis or constipation). However, bowel dysfunction is less urgent than preventing or addressing skin integrity issues, which can rapidly deteriorate and lead to systemic infections like sepsis. Auscultation of lung sounds (D) is crucial for detecting complications like atelectasis or pneumonia, which immobile clients are at higher risk for due to shallow breathing and poor secretion clearance. However, these respiratory issues typically develop over time, whereas skin breakdown can occur within hours of unrelieved pressure. While respiratory assessment is vital, it does not supersede the need for immediate skin inspection, as pressure injuries can progress quickly and are often preventable with prompt action. The incorrect choices (A, B, D) represent important but lower-priority assessments for an immobile client. They address potential complications of immobility but fail to target the most immediate and preventable risk. Skin inspection (C) is the priority because it directly addresses the client’s highest vulnerability—pressure injuries—which require proactive monitoring to avert severe consequences. This prioritization aligns with the nursing principle of addressing the most critical, life-altering risks first.

Correct Answer: D

Rationale: Administering eye drops correctly is critical for both medication efficacy and infection prevention. The action described in **Choice D (touching the dropper to the eye)** clearly indicates a need for further education because it introduces contamination risks. The dropper tip should never contact the eye, eyelids, or any other surface, as this can introduce bacteria or other pathogens into the medication bottle, leading to potential infections like conjunctivitis or keratitis. Proper technique involves holding the dropper close to the eye (about an inch away) without making direct contact to maintain sterility. **Choice A (setting the cap down without contaminating it)** is correct and does not require additional teaching. Placing the cap in a clean, dry location (e.g., upside down on a tissue) prevents contamination, ensuring the medication remains sterile. This demonstrates the client’s understanding of aseptic technique. **Choice B (dropping medication into the conjunctival sac)** is also correct. The conjunctival sac, the pocket formed by pulling down the lower eyelid, is the ideal location for instilling drops. This ensures proper absorption and minimizes spillage. The client’s ability to target this area correctly shows they have been taught the proper administration technique. **Choice C (washing hands before instilling drops)** reflects proper hygiene and is essential to prevent transferring pathogens from the hands to the eye. Handwashing reduces the risk of infection, and the client’s adherence to this step indicates they are following best practices. In summary, **Choice D** is the only option that reveals a critical error in technique, as it compromises sterility and increases infection risk. The other choices (A, B, and C) demonstrate correct practices that align with standard eye drop administration protocols. Clients must be reminded to avoid touching the dropper to the eye or any surface to maintain medication safety and effectiveness. Correcting this behavior is crucial to ensure therapeutic outcomes and prevent complications.

Correct Answer: D

Rationale: Rationale: **Correct Answer: D – Sudden increase in drainage is expected** A sudden increase in drainage from under a cast is **not normal** and indicates a potential complication, such as infection, bleeding, or tissue breakdown. This requires immediate medical evaluation to prevent further harm. Teaching the client to expect increased drainage is incorrect because it could lead to delayed reporting of serious issues, worsening the condition. **Incorrect Choices:** **A: Use a sling to alleviate fatigue** Using a sling is correct teaching because it supports the immobilized arm, reduces strain on muscles and joints, and prevents unnecessary movement that could displace the cast. A sling also helps maintain proper positioning, minimizing discomfort. This is appropriate nursing advice, not incorrect teaching. **B: Elevate the arm above the heart to reduce swelling** Elevation is a standard intervention to minimize swelling by promoting venous return and reducing fluid accumulation in the injured area. Failure to elevate can lead to increased pain, compromised circulation, or even compartment syndrome. This instruction is correct and should be reinforced, not dismissed. **C: Report 'hot spots' felt under the cast** A "hot spot" (localized warmth) under the cast is a red flag for infection or pressure necrosis. Early reporting allows prompt intervention, such as cast removal or antibiotic treatment. Teaching the client to monitor and report this is essential for preventing complications, making this correct guidance, not incorrect. **Summary of Errors in Choices A-C:** These options are all **correct nursing instructions** and would not represent incorrect teaching. Only **D** inaccurately normalizes a concerning symptom, posing a risk to the client’s recovery. Recognizing abnormal vs. expected post-cast symptoms is critical for patient safety.