Nokea
The nurse is caring for a child in a plaster-of-Paris hip spica cast. To facilitate drying, the nurse should:
- A. Use a small hand-held hair dryer set on medium heat.
- B. Place a small heater near the child's bed.
- C. Turn the child at least every two hours.
- D. Allow one side to dry before changing positions.
Correct Answer: C
Rationale: Turning the child every two hours ensures even drying of the cast and prevents pressure sores, promoting proper cast setting.
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The most important reason to closely assess circumferential burns at least every hour is that they may result in:
- A. Hypovolemia
- B. Renal damage
- C. Ventricular arrhythmias
- D. Loss of peripheral pulses
Correct Answer: D
Rationale: Full-thickness circumferential burns are nonelastic and create an internal tourniquet effect, compromising distal blood flow in extremities or respiratory motion in the torso, leading to loss of peripheral pulses.
The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:
- A. Notify her doctor
- B. Start an IV
- C. Reposition the client
- D. Readjust the monitor
Correct Answer: C
Rationale: Variable decelerations are often caused by umbilical cord compression. Repositioning the client (e.g. to the left side) can relieve pressure on the cord and improve fetal oxygenation. Notifying the doctor or starting an IV are secondary if repositioning resolves the issue.
Proper positioning for the child who is in Bryant's traction is:
- A. Both hips flexed at a 90-degree angle with the knees extended and the buttocks elevated off the bed
- B. Both legs extended, and the hips are not flexed
- C. The affected leg extended with slight hip flexion
- D. Both hips and knees maintained at a 90-degree flexion angle, and the back flat on the bed
Correct Answer: A
Rationale: The child's weight supplies the countertraction for Bryant's traction; the buttocks are slightly elevated off the bed, and the hips are flexed at a 90-degree angle. Both legs are suspended by skin traction. The child in Buck's extension traction maintains the legs extended and parallel to the bed. The child in Russell traction maintains hip flexion of the affected leg at the prescribed angle with the leg extended. The child in '90-90' traction maintains both hips and knees at a 90-degree flexion angle and the back is flat on the bed.
The nurse is caring for a client with a diagnosis of chorioamnionitis. Which intervention is most appropriate?
- A. Administer antibiotics
- B. Monitor fetal heart tones
- C. Prepare for delivery
- D. All of the above
Correct Answer: D
Rationale: Chorioamnionitis requires antibiotics for infection fetal heart tone monitoring for distress and preparation for delivery (vaginal or cesarean) if maternal or fetal condition worsens. All interventions are appropriate.
A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use, and haloperidol (Haldol) 5 mg IM is administered. After 1 hour, his behavior is more subdued, but he tells the nurse, 'The devil followed me into this room, I see him standing in the corner with a big knife. When you leave the room, he's going to cut out my heart.' The nurse's best response is:
- A. I know you're feeling frightened right now, but I want you to know that I don't see anyone in the corner.'
- B. You'll probably see strange things for a while until the PCP wears off.'
- C. Try to sleep. When you wake up, the devil will be gone.'
- D. You're probably feeling guilty because you used illegal drugs tonight.'
Correct Answer: A
Rationale: The nurse is the client's link to reality. This response validates the authenticity of the client's experience by casting doubt on his belief and reinforcing reality.