Page 2144 - Saunders Comprehensive Review For NCLEX-RN

Rationale: A casted extremity is elevated continuously for the first 24 to 48 hours
to minimize swelling and promote venous drainage. Options 1, 2, and 3 are
incorrect.
Test-Taking Strategy: Note the strategic word, best. Recalling that edema is a
concern following an injury and knowledge of the effects of gravity on edema will
direct you to the correct option.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Adult Health: Musculoskeletal
Health Problem: Adult Health: Musculoskeletal: Skeletal Injury
Priority Concepts: Perfusion; Tissue Integrity
Reference: Ignatavicius, Workman, Rebar (2018), p. 1039.

743. Answer: 1

Rationale: A plaster cast must remain dry to keep its strength. The cast should be
handled with the palms of the hands, not the fingertips, until fully dry; using the
fingertips results in indentations in the cast and skin pressure under the cast. Air
should circulate freely around the cast to help it dry; the cast also gives off heat as it
dries. The client should never scratch under the cast because of the risk of altered
skin integrity; the client may use a hair dryer on the cool setting to relieve an itch.
Test-Taking Strategy: Focus on the subject, client understanding about cast care.
Knowing that a wet cast can be dented with the fingertips, causing pressure
underneath, helps eliminate option 3 first. Knowing that the cast needs to dry helps
eliminate option 2 next. Option 4 is dangerous to skin integrity and is also
eliminated. Remember that plaster casts, once they have dried after application,
should not become wet.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Evaluation
Content Area: Adult Health: Musculoskeletal
Health Problem: Adult Health: Musculoskeletal: Skeletal Injury
Priority Concepts: Client Education; Safety
Reference: Ignatavicius, Workman, Rebar (2018), p. 1039.

744. Answer: 2

Rationale: Crutches are measured so that the tops are 2 to 3 fingerwidths from the
axillae. This ensures that the client’s axillae are not resting on the crutch or bearing
the weight of the crutch, which could result in injury to the nerves of the brachial
plexus. Although the conditions in options 1, 3, and 4 can occur, they are not the
most likely result from resting the axilla directly on the crutches.
Test-Taking Strategy: Note the strategic words, most likely, and focus on the data
in the question. Recalling the risk associated with brachial nerve plexus injury will
direct you to the correct option.
Level of Cognitive Ability: Applying

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