Nokea
Which nursing interventions should be included in the care plan of a child in skeletal traction? Select all that apply.
- A. Maintain the child in the prone position.
- B. Clean the pin site every 8 hours.
- C. Release weights on the traction every 2 hours.
- D. Monitor client for signs of cloudy urine.
- E. Cover protruding tips of pins with protective materials.
Correct Answer: B,D,E
Rationale: Cleaning pin sites every 8 hours prevents infection, monitoring for cloudy urine detects urinary tract infections due to immobility, and covering pin tips ensures safety. Prone position is not standard, and weights should not be released.
You may also like to solve these questions
Which statement by the child indicates teaching about the use of ibuprofen (Motrin) has been effective?
- A. I should take Motrin every day to control my joint inflammation.
- B. I should take Motrin when my temperature is 101°F (38.3°C) or higher.
- C. I should take Motrin only when I'm having joint pain.
- D. I should take Motrin every day to thin my blood.
Correct Answer: C
Rationale: Ibuprofen is used as needed for pain and inflammation in juvenile rheumatoid arthritis (JRA). Taking it only for joint pain reflects correct understanding, as daily use is not typically required unless prescribed.
The nurse assesses that the 8-hour-old infant’s axillary temperature is 97°F (36.1°C). Which intervention should the nurse implement first?
- A. Document the findings as abnormal.
- B. Place the infant under a radiant warmer.
- C. Feed the infant formula that is warmed.
- D. Call the HCP to report the temperature.
Correct Answer: B
Rationale: An axillary temperature of 97°F is below the normal range (97.7°F–98.9°F). The infant should be gradually rewarmed under a radiant warmer. Documentation follows intervention feeding warm formula is unnecessary and HCP notification is needed only if warming fails.
Which response by the nurse provides the best clarification about the disease process?
- A. If you're afraid of getting HIV, you'll be safer if you avoid having sex with past sex partners.
- B. An HIV-positive individual may not develop symptoms of AIDS for years.
- C. HIV can only be transmitted when symptoms of AIDS are present.
- D. The medication prescribed for AIDS also protects against HIV infection.
Correct Answer: B
Rationale: HIV can be asymptomatic for years, during which it is still transmissible, making this clarification critical for understanding the disease process and transmission risk.
Which intervention is most appropriate initially for an 8-year-old child who selects the fourth face on the Wong-Baker FACES Pain Rating Scale?
- A. Take no action; the child is pain-free.
- B. Provide diversional activities to relieve the child's pain.
- C. Document findings, and recheck the child later.
- D. Give the prescribed analgesic to relieve the pain.
Correct Answer: D
Rationale: The fourth face on the Wong-Baker FACES Pain Rating Scale indicates moderate to severe pain, requiring administration of a prescribed analgesic for effective pain relief.
The nurse is discharging the 3-day-old term newborn with a right-sided cephalohematoma. The nurse should instruct the parents to observe their infant closely over the next week for the development of which problem associated with the cephalohematoma?
- A. Jaundice
- B. Difficulty feeding
- C. Pale extremities
- D. Bulging on the right side of the head with crying
Correct Answer: A
Rationale: Cephalohematoma resolution causes RBC hemolysis leading to jaundice. It doesn’t affect feeding cause paleness or bulge with crying.