A patient who slipped and fell in the shower at home has a proximal left humerus fracture immobilized with a long-arm cast and a sling. Which nursing intervention will be included in the plan of care?

Correct Answer: C

Rationale: The correct answer is C: Assess the left axilla and change absorbent dressings as needed. This is important to monitor for skin breakdown and infection due to the immobilization of the left arm. The axilla is a common site for pressure sores in patients with arm casts. Using surgical net dressing to hang the arm from an IV pole (A) is not appropriate as it can cause discomfort and compromise circulation. Immobilizing the fingers of the left hand with gauze dressings (B) is unnecessary and can lead to stiffness and decreased circulation. Assisting the patient in passive ROM for the right arm (D) is not directly related to the care of the left humerus fracture.

Correct Answer: D

Rationale: The correct answer is D: Check the patient’s alertness and orientation. This is the priority because it assesses the patient's level of consciousness and neurological status, which is crucial in determining the severity of the facial fracture and any potential associated injuries. Assessing alertness and orientation helps in identifying any signs of head trauma or neurological deficits. This initial assessment guides further interventions and ensures timely and appropriate care. Incorrect choices: A: Assess for nasal bleeding and pain - This is important but assessing the patient's alertness and orientation takes precedence. B: Apply ice to the face to reduce swelling - While this can be helpful later, it is not the first priority in a patient with a facial fracture. C: Use a cervical collar to stabilize the spine - Stabilizing the spine is important in trauma, but in this scenario, assessing the patient's alertness and orientation is more critical.

Correct Answer: C

Rationale: The correct answer is C because keeping the head elevated slightly and flexing the knees when resting in bed helps to reduce pressure on the lower back, promoting relaxation of the muscles and reducing muscle spasms. Elevating the head slightly can also help maintain proper spinal alignment. Choice A is incorrect because keeping both feet flat on the floor when prolonged standing is required may not directly address the low back pain and muscle spasms. Choice B is incorrect because twisting gently from side to side can aggravate the muscle spasms and strain the lower back muscles further. Choice D is incorrect because cold packs can actually help reduce muscle spasms and inflammation, so avoiding their use would not be beneficial for managing acute low back pain and muscle spasms.

Correct Answer: D

Rationale: The correct answer is D because a temperature of 101.4°F indicates possible infection post-surgery, requiring immediate notification of the healthcare provider for further evaluation and treatment. Elevated temperature can indicate systemic infection. A: Serous wound drainage is expected post-surgery and not concerning. B: Right arm pain with movement is typical after surgical reduction and should be managed with pain medication. C: Right arm muscle spasms can be a normal response to surgery and may resolve with proper rest and care.

Correct Answer: C

Rationale: The correct answer is C. Adding oil to bath water can exacerbate contact dermatitis by further irritating the skin. Oil can create a barrier that traps irritants and moisture, worsening symptoms. The other options are appropriate for managing pruritus in contact dermatitis. A: Cool, wet cloths or compresses can provide relief by soothing and reducing inflammation. B: Cool or tepid baths help to soothe the skin and reduce itching. D: Rubbing dry with a towel after bathing helps prevent skin maceration and further irritation. Adding oil to bath water is contra-indicated in contact dermatitis management.