Difficulty: Medium
Average Score: 66%
Full-length
Passage / Scenario
A 20-year-old client has a cast applied for a fracture of the right femur. Three hours later, the client complains that it is hot and painful under his cast.Which of the following is the MOST appropriate action for the nurse to take?
Correct answer
B
Rationale
Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) heat is sign of pressure (2) correct-heat is sign of pressure, pressure limits circulation (3) too early to see signs of infection (4) all complaints must be investigated, medication would mask signs of pressure, assessment first step