Nokea
Because of the length of time the client must remain in skeletal traction, the nurse correctly assesses for evidence of skin breakdown in which area?
- A. Over the child's calves
- B. Over the child's scapulae
- C. On the child's knees
- D. On the child's buttocks
Correct Answer: D
Rationale: Prolonged immobility in traction increases pressure on the buttocks, a common site for skin breakdown due to constant contact with the bed.
You may also like to solve these questions
The mother of a healthy 15-hour-old term newborn asks the nurse if the PKU blood test could be completed now on her infant because she and her infant are being discharged to home. Which statement should be the basis for the nurse’s response?
- A. The PKU test must be completed when the infant is at least 1 month of age.
- B. The parents must be required to obtain the test within the first week after discharge if completed before 24 hours of age.
- C. The PKU test is best if completed after the infant is 24 hours old but before 7 days of age.
- D. The PKU test is not needed if the infant is tolerating feedings without diarrhea or vomiting.
Correct Answer: C
Rationale: The PKU test is most accurate after 24 hours and before 7 days allowing sufficient protein intake. Early discharge requires follow-up testing and feeding tolerance doesn’t exempt testing.
Which nursing actions are most appropriate to include in the care plan of a child with nephrotic syndrome? Select all that apply.
- A. Restricting the intake of protein
- B. Weighing the child daily
- C. Completing range-of-motion exercises
- D. Measuring abdominal circumference
- E. Collecting a 24-hour urine specimen
- F. Monitoring blood urea nitrogen (BUN) and creatinine levels
Correct Answer: B,C,D,E,F
Rationale: Daily weighing monitors fluid status, range-of-motion exercises prevent immobility complications, measuring abdominal circumference tracks ascites, collecting urine assesses proteinuria, and monitoring BUN/creatinine evaluates kidney function. Protein restriction is not typical.
Preterm labour is defined as spontaneous onset of painful regular uterine contractions at any time prior to:
- A. A stage of fetal viability.
- B. The second stage of labour.
- C. The 32nd week of gestation.
- D. The 37th week of gestation.
- E. The 40th week of gestation.
Correct Answer: D
Rationale: Preterm labor is defined as regular contractions before 37 weeks gestation leading to cervical change. This is the standard cutoff for preterm delivery.
During preoperative preparation, which nursing action is most appropriate?
- A. Give analgesics.
- B. Give nothing by mouth (NPO).
- C. Give an enema.
- D. Apply heat to the abdomen.
Correct Answer: B
Rationale: Keeping the patient NPO prevents aspiration during surgery and reduces complications, as food in the stomach could interfere with anesthesia.
When caring for a child with measles, which precaution is most appropriate for the nurse to implement?
- A. Standard precautions
- B. Droplet precautions
- C. Contact precautions
- D. Airborne precautions
Correct Answer: D
Rationale: Measles is highly contagious and spreads via airborne transmission, requiring airborne precautions, including a negative-pressure room and N95 respirator use.