Nokea
A 3-year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should:
- A. Expose the cast to air and turn the child frequently.
- B. Use a heat lamp to reduce the drying time.
- C. Handle the cast with the abductor bar.
- D. Turn the child as little as possible.
Correct Answer: A
Rationale: After a hip spica cast is applied, it is important to facilitate drying by exposing the cast to air and turning the child frequently, approximately every 2 hours. This helps ensure even drying and prevents skin breakdown. Using a heat lamp can cause burns and should be avoided. Handling the cast with the abductor bar is not necessary for the drying process and may cause discomfort to the child. Turning the child as little as possible is not recommended as regular turning helps prevent complications like pressure ulcers and stiffness.
You may also like to solve these questions
A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is
- A. Surgical repair of a diseased coronary artery.
- B. Placement of an automatic internal cardiac defibrillator.
- C. Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow.
- D. Non-invasive radiographic examination of the heart.
Correct Answer: C
Rationale: Percutaneous transluminal coronary angioplasty (PTCA) is a procedure that involves compressing plaque against the wall of a diseased coronary artery to improve blood flow. It is a minimally invasive procedure performed during a cardiac catheterization to open blockages in the coronary arteries. Surgical repair of a diseased coronary artery refers to procedures like coronary artery bypass grafting (CABG), not PTCA. Placement of an automatic internal cardiac defibrillator is a different intervention used for managing cardiac arrhythmias, not for improving coronary blood flow. A non-invasive radiographic examination of the heart would typically refer to procedures like a cardiac CT scan or an MRI, not PTCA.
A client has just been diagnosed with active tuberculosis. Which of the following nursing interventions should the nurse perform to prevent transmission to others?
- A. Begin drug therapy within 72 hours of diagnosis
- B. Place the client in a positive-pressure room
- C. Initiate standard precautions
- D. Place the client in a negative-pressure room
Correct Answer: D
Rationale: A client diagnosed with active tuberculosis should be placed in isolation in a negative-pressure room to prevent transmission of infection to others. Placing the client in a negative-pressure room ensures that air is exhausted to the outside and received from surrounding areas, preventing tuberculin particles from traveling through the ventilation system and infecting others. Initiating standard precautions, as mentioned in choice C, is essential for infection control but is not specific to preventing transmission in the case of tuberculosis. Beginning drug therapy within 72 hours of diagnosis, as in choice A, is crucial for the treatment of tuberculosis but does not directly address preventing transmission. Placing the client in a positive-pressure room, as in choice B, is incorrect as positive-pressure rooms are used for clients with compromised immune systems to prevent outside pathogens from entering the room, which is not suitable for a client with active tuberculosis.
A man is receiving heparin subcutaneously. The patient has dementia and lives at home with a part-time caretaker. The nurse is most concerned about which side effect of heparin?
- A. Back Pain
- B. Fever and Chills
- C. Risk for Bleeding
- D. Dizziness
Correct Answer: C
Rationale: The correct answer is 'Risk for Bleeding.' A patient with dementia may have impaired judgment and may be prone to falls or injuries, increasing the risk of bleeding while on heparin therapy. Monitoring for signs of bleeding is crucial in this situation. Choice A, 'Back Pain,' is not a common side effect of heparin. Choice B, 'Fever and Chills,' is not a typical side effect of heparin but may indicate other underlying conditions. Choice D, 'Dizziness,' is not a common side effect of heparin and is not the primary concern in this scenario.
Which of the following techniques can help to prevent skin irritation or breakdown around a tracheostomy site?
- A. Manage secretions by providing suction on a regular basis
- B. Cleanse the site daily with a mixture of povidone-iodine and water
- C. Avoid using tube ties to secure the tube
- D. None of the above
Correct Answer: A
Rationale: Excess secretions from the tracheostomy tube can collect near the stomal opening and cause skin breakdown. Management of secretions through regular suctioning will keep the area clean and dry, minimizing skin irritation. Choice B, cleansing the site daily with povidone-iodine and water, is incorrect as it may lead to skin irritation due to the harshness of povidone-iodine. Choice C, avoiding tube ties to secure the tube, is also incorrect as securing the tube is essential for stability. Choice D, 'None of the above,' is incorrect as managing secretions through suctioning is crucial in preventing skin irritation.
Which topic is most important to include in patient teaching for a 41-year-old patient diagnosed with early alcoholic cirrhosis?
- A. Maintaining good nutrition
- B. Avoiding alcohol ingestion
- C. Taking lactulose (Cephulac)
- D. Using vitamin B supplements
Correct Answer: B
Rationale: The most important topic to include in patient teaching for a 41-year-old patient diagnosed with early alcoholic cirrhosis is avoiding alcohol ingestion. Alcohol abstinence is crucial in stopping or reversing the progression of the disease. While maintaining good nutrition, taking lactulose (Cephulac), and using vitamin B supplements are important interventions in managing cirrhosis, abstaining from alcohol is the priority for this patient to prevent further damage to the liver and halt disease progression.