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Which interventions should the nurse implement for a child with a newly applied fiberglass hip-Spica cast?
- A. Use a hair dryer on a low setting to help dry the cast.
- B. Place on a Bradford frame for elevation off the bed.
- C. Place pillows to support the child's lower extremities.
- D. Turn the child every 2 hours and monitor the CMS.
- E. Petal the perineal area and other edges of the cast.
Correct Answer: C,D,E
Rationale: Pillows provide support, turning prevents pressure sores, and petaling protects skin around cast edges.
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The nurse correctly instructs the client to avoid which type of fluid?
- A. Milk
- B. Alcohol
- C. Cranberry juice
- D. Carbonated drinks
Correct Answer: B
Rationale: Alcohol increases uric acid levels, worsening gout.
What interventions should the nurse implement for a child who sustained a twisting injury of the right arm?
- A. Elevate the arm and apply ice at the site of the child's injury.
- B. Wrap the child's arm with an elastic bandage.
- C. Telephone the child's parent to discuss the injury.
- D. Call the health care provider identified by the child.
- E. Make arrangements to obtain an x-ray of the child's arm.
- F. Meet with the student who caused the child's injury.
Correct Answer: A,B,C
Rationale: Elevation, ice, and wrapping reduce swelling; contacting the parent ensures proper follow-up.
What is the most important factor for the nurse to consider when teaching the child who has CP?
- A. Current age
- B. Type of cerebral palsy
- C. Prior illness experience
- D. Developmental level
Correct Answer: D
Rationale: Developmental level is critical to tailor teaching to the child's cognitive and physical abilities.
A client sustained a fractured femur in a motor-vehicle accident. Which data require immediate intervention by the nurse? Select all that apply.
- A. The client requests pain medication to sleep.
- B. The client has eupnea and normal sinus rhythm.
- C. The client has petechiae over the neck and chest.
- D. The client has a high arterial oxygen level.
- E. The client has yellow globules floating in the urine.
Correct Answer: C,E
Rationale: Petechiae and yellow globules suggest fat embolism syndrome, requiring immediate intervention. Pain medication, normal breathing, and high oxygen are not urgent.
Which nursing intervention is most important after the client returns from the myelogram?
- A. Turning off the room's bright lights
- B. Withholding food and fluids for 12 hours
- C. Administering sedatives every 6 hours
- D. Encouraging a high fluid intake
Correct Answer: D
Rationale: A high fluid intake post-myelogram with water-soluble dye helps excrete the contrast, reducing the risk of complications like seizures or renal issues. Other interventions are less critical.