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When teaching the family of an older infant who has had a hip spica cast applied for developmental dysplasia of the hip, which information should the nurse include when describing the abduction stabilizer bar?
- A. It can be adjusted to a position of comfort.
- B. It is used to lift the child.
- C. It adds strength to the cast.
- D. It is necessary to turn the child.
Correct Answer: C
Rationale: The abduction stabilizer bar maintains the legs in abduction to promote hip joint stability and adds structural strength to the cast.
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A child with hemophilia presents with a burning sensation in the knee and reluctance to move the body part. The nurse collaborates with the care team to provide the treatment and
- A. Administer an aspirin-containing compound.
- B. Institute Rest, Ice, Compression, and Elevation (RICE).
- C. Begin physical therapy with active range of motion.
- D. Initiate skin traction.
Correct Answer: B
Rationale: RICE reduces swelling and bleeding in hemophilic joint bleeds. Aspirin worsens bleeding, active motion is harmful, and traction is inappropriate.
A toddler diagnosed with nephrotic syndrome has a nursing diagnosis of Excess fluid volume related to fluid accumulation in the tissues. Which measure should the nurse anticipate including in the child's plan of care?
- A. Limiting visitors to 2 to 3 hours a day.
- B. Maintaining strict bed rest.
- C. Testing urine specific gravity every shift.
- D. Weighing the child before breakfast.
Correct Answer: D
Rationale: Daily weights monitor fluid balance.
The physician orders intravenous fluid replacement therapy with potassium chloride to be added for a child with severe gastroenteritis. Before adding the potassium chloride to the intravenous fluid, which of the following assessments would be most important?
- A. Ability to void.
- B. Passage of stool today.
- C. Baseline electrocardiogram.
- D. Serum calcium level.
Correct Answer: A
Rationale: Ensuring the ability to void confirms renal function before administering potassium.
Which of the following assessment findings should alert the nurse to suspect appendicitis in a male adolescent complaining of severe abdominal pain?
- A. Abdomen appears slightly rounded.
- B. Bowel sounds are heard twice in 2 minutes.
- C. All four abdominal quadrants reveal tympany.
- D. The client demonstrates a cremasteric reflex.
Correct Answer: B
Rationale: Decreased bowel sounds suggest appendicitis due to peritoneal irritation.
When developing the plan of care for a child with cystic fibrosis (CF) who is scheduled to receive postural drainage, the nurse should anticipate performing postural drainage at which of the following times?
- A. After meals.
- B. Before meals.
- C. After rest periods.
- D. Before inhalation treatments.
Correct Answer: B
Rationale: Postural drainage should be performed before meals to avoid discomfort and reduce the risk of vomiting, as it involves positioning to facilitate mucus clearance.