Nokea
A child has had a cast placed on his left arm following a diagnosed fracture. Which actions should the nurse take? (Select all that apply)
- A. Smooth the rough edges of the cast to maintain skin integrity
- B. Wear sterile gloves when touching or removing the cast
- C. Monitor capillary refill and color of nail beds of the left-hand
- D. Monitor for signs of pain
- E. Assess for numbness, tingling, or decreased sensation of the left hand.
Correct Answer: A,C,D,E
Rationale: Choice A rationale: Smoothing the rough edges of the cast can help maintain skin integrity and prevent skin irritation or injury. Choice C rationale: Monitoring capillary refill and color of nail beds of the left hand is important to assess the circulation to the hand and ensure that the cast is not too tight. Choice D rationale: Monitoring for signs of pain can help detect complications such as compartment syndrome, which is a serious condition that can occur if pressure within the muscles builds to dangerous levels. Choice E rationale: Assessing for numbness, tingling, or decreased sensation of the left hand is important as these can be signs of nerve damage or compression. Choice B rationale: Wearing sterile gloves when touching or removing the cast is not typically necessary. The outside of a cast is not a sterile environment, and healthcare providers do not usually wear sterile gloves when handling it.
You may also like to solve these questions
A nurse is preparing to administer acetaminophen 10mg/kg PO to a preschool child for fever. The child weighs 22 lb. Available is acetaminophen liquid 160 mg/5 mL. How many mL should the nurse administer?
- A. 3.125 mL
Correct Answer: A
Rationale: The child weighs 22 lb, which is approximately 10 kg (since 1 kg is approximately 2.2 lb). The prescribed dose of acetaminophen is 10 mg/kg. Step 1 is: Calculate the total dose of acetaminophen for the child. This is done by multiplying the child's weight in kg by the prescribed dose in mg/kg. 10 kg×10 mg/kg=100 mg The available acetaminophen liquid is 160 mg/5 mL. Step 2 is: Calculate the volume of acetaminophen liquid to administer. This is done by setting up a proportion with the total dose of acetaminophen and the concentration of the available liquid. x mL100 mg=5 mL160 mg Solving for x gives: x=160 mg mg×5 mL=3.125 mL Therefore, the nurse should administer approximately 3.125 mL of the acetaminophen liquid.
A nurse is gathering information from a 1-year-old child who has been diagnosed with Wilms' tumor. Which of the following symptoms should the nurse anticipate?
- A. Jaundice
- B. Abdominal mass
- C. Swollen joints
- D. Diarrhea
Correct Answer: B
Rationale: Jaundice, a yellowing of the skin and eyes, is not typically a symptom of Wilms' tumor. It is more commonly associated with conditions that cause liver dysfunction. An abdominal mass is one of the most common symptoms of Wilms' tumor. Parents or healthcare providers may feel a lump or swelling in the child's abdomen. Swollen joints are not a typical symptom of Wilms' tumor. They are more commonly associated with conditions that affect the joints, such as juvenile arthritis. Diarrhea is not a typical symptom of Wilms' tumor. It is more commonly a symptom of gastrointestinal illnesses.
A nurse at a pediatrician's office answers a phone call from a parent whose child just ingested 15 vitamin tablets with added ferrous sulfate. Which of the following instructions should the nurse give to the parent?
- A. Administer syrup of ipecac.
- B. Give the child 120 mL (8 oz) of orange juice.
- C. Contact the poison control center.
- D. Provide the child with a high-carbohydrate snack.
Correct Answer: C
Rationale: Administering syrup of ipecac is not recommended in cases of iron overdose. Ipecac was once used to induce vomiting in cases of poisoning, but it is no longer recommended due to potential complications and lack of evidence for effectiveness. Giving the child orange juice will not help in this situation. While vitamin C can enhance iron absorption, it does not have an effect on iron that has already been absorbed into the body. Contacting the poison control center is the appropriate action. They can provide immediate advice on what to do in cases of potential iron overdose. Providing a high-carbohydrate snack will not help in this situation. It will not affect the absorption or toxicity of the iron.
A nurse is caring for an adolescent following the application of a plaster cast for a fractured right tibia. Which of the following actions should the nurse take?
- A. Discourage the client from ambulating.
- B. Use a hair dryer on a hot setting to dry the cast.
- C. Keep the client's leg in a dependent position.
- D. Perform a neurovascular check of the lower extremities.
Correct Answer: D
Rationale: Discouraging the client from ambulating is not the best action. While it's important to limit weight-bearing activities initially, movement is encouraged to promote circulation and prevent complications such as deep vein thrombosis. Using a hair dryer on a hot setting to dry the cast is not recommended. Heat can cause the cast to dry out and crack, and it can also burn the skin. Keeping the client's leg in a dependent position is not advisable. This can lead to increased swelling and pain, and potentially delay healing. Performing a neurovascular check of the lower extremities is the correct action. This involves assessing for pain, pallor, pulselessness, paresthesia, and paralysis. These checks are crucial for monitoring for complications such as compartment syndrome and ensuring the cast is not too tight.
A nurse is preparing a 4-year-old child for discharge following a bilateral myringotomy with tympanostomy tube placement. The mother asks what to do if the tubes fall out. Which of the following instructions should the nurse give the parent?
- A. Gently reinsert the tubes.
- B. Call the health care clinic to report that the tubes have fallen out.
- C. Reassure the mother that the tubes will not fall out.
- D. Take the child to an emergency department.
Correct Answer: B
Rationale: It is not advisable for a parent to attempt to reinsert the tubes if they fall out. This could potentially cause harm to the child's ear. If the tubes fall out, the parent should call the healthcare clinic to report this. The healthcare provider can then decide on the appropriate next steps. It is not accurate to reassure the mother that the tubes will not fall out. Tympanostomy tubes are designed to fall out on their own after a certain period of time. Taking the child to an emergency department is not necessary unless there are signs of infection or other complications.