A home health nurse assesses a client with diabetes who has a new cast on the arm. The nurse notes the client's fingers are pale, cool, and slightly swollen. Which action should the nurse take first?
a. Raise the arm above the level of the heart.
b. Encourage range of motion.
c. Apply heat to the affected hand.
d. Bivalve the cast to decrease pressure.
ANS: A
Arm casts can impair circulation when the arm is in the dependent position. The nurse should immediately elevate the arm above the level of the heart, ensuring that the hand is above the elbow, and should re-assess the extremity in 15 minutes. If the fingers are warmer and less swollen, the cast is not too tight and adjustments do not need to be made, but a sling should be worn when the client is upright. Encouraging range of motion would not assist the client as much as elevating the arm. Heat would cause increased edema and should not be used. If the cast is confirmed to be too tight, it could be bivalved.
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