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A nurse is caring for a child following an open reduction and internal fixation of a fractured femur and application of a cast. The cast has a window cut in it for viewing of the incision. Which of the following actions should the nurse take first?
- A. Remove the window and view the incision.
- B. Medicate the client for pain.
- C. Perform neurovascular checks of the affected extremity.
- D. Turn the client so the cast will dry on all sides.
Correct Answer: C
Rationale: Performing neurovascular checks is the highest priority to ensure that circulation sensation and movement are intact.
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A nurse is caring for an adolescent client who is receiving carbamazepine (Tegretol) for partial seizure disorder. Which of the following statements by the adolescent's parent is the priority for the nurse to address?
- A. He takes his medication between meals with water.
- B. He only sleeps about 5 hours each night.
- C. He seems to be getting a lot more bumps and bruises lately.
- D. He has not been eating as much lately.
Correct Answer: C
Rationale: Increased bruising can indicate thrombocytopeniaa potential side effect of carbamazepine which can lead to serious bleeding issues.
A nurse is reinforcing teaching with an adolescent who has type 1 diabetes mellitus. Which of the following instructions should the nurse include In the teaching?
- A. Inject insulin in the deltoid muscle.
- B. Take glyburide with breakfast.
- C. Obtain an influenza vaccine annually.
- D. Administer glucagon for hyperglycemia.
Correct Answer: C
Rationale: People with diabetes are at higher risk for complications from influenza so annual vaccination is recommended.
A nurse is reinforcing discharge teaching with the parent of a child who has a new diagnosis of diabetes mellitus. Which of the following statements by the parent requires a clarification of the teaching?
- A. Sweating can occur with hypoglycemia.
- B. My son might have nausea and vomiting with hypoglycemia.
- C. My son might complain of feeling shaky when he has a low blood glucose level.
- D. The onset of low blood glucose usually occurs rapidly.
Correct Answer: B
Rationale: Nausea and vomiting are typically associated with hyperglycemia and diabetic ketoacidosis (DKA) not hypoglycaemia. Hypoglycaemia usually presents with symptoms like sweating shakiness confusion and hunger.
A nurse is preparing a 9-year-old child for an IV catheter insertion. Which of the following actions should the nurse take first?
- A. Ask the child what he knows about the procedure.
- B. Allow the child to see and touch IV tubing and supplies.
- C. Describe the procedure using visual aids.
- D. Explain to the child's parents what role they will have during the procedure.
Correct Answer: A
Rationale: Understanding the child's knowledge and feelings about the procedure helps tailor the explanation to address any misconceptions and reduce anxiety.
A nurse is reinforcing teaching about preventing disease transmission with the parents of a child who has a streptococcal infection. Which of the following instructions should the nurse include?
- A. I'll give him acetaminophen for the pain.
- B. I'll discard his toothbrush and buy another.
- C. I'll continue to encourage him to drink lots of fluids.
- D. I'll take his temperature every 4 hours.
Correct Answer: B
Rationale: Replacing the toothbrush after starting antibiotics helps to reduce the risk of reinfection.