A child has had a cast placed on his left arm following a diagnosed fracture. Which actions should the nurse take? (Select all that apply)

Smooth the rough edges of the cast to maintain skin integrity

Wear sterile gloves when touching or removing the cast

Monitor capillary refill and color of nail beds of the left-hand

Monitor for signs of pain

Assess for numbness, tingling, or decreased sensation of the left hand.

Answer and Explanation

Correct Answer : A,C,D,E

Choice A rationale
Smoothing the rough edges of the cast can help maintain skin integrity and prevent skin irritation or injury.
Choice C rationale
Monitoring capillary refill and color of nail beds of the left hand is important to assess the circulation to the hand and ensure that the cast is not too tight.
Choice D rationale
Monitoring for signs of pain can help detect complications such as compartment syndrome, which is a serious condition that can occur if pressure within the muscles builds to dangerous levels.
Choice E rationale
Assessing for numbness, tingling, or decreased sensation of the left hand is important as these can be signs of nerve damage or compression.
Choice B rationale
Wearing sterile gloves when touching or removing the cast is not typically necessary. The outside of a cast is not a sterile environment, and healthcare providers do not usually wear sterile gloves when handling it.

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Correct Answer is C

Explanation

The correct answer is (C) Determine if the toddler is voiding.

Choice A: Initiate isotonic fluids with 20 mEq/L potassium chloride. While it is important to maintain hydration in a child with acute gastroenteritis, initiating isotonic fluids with 20 mEq/L potassium chloride is not the first action a nurse should take. The child’s hydration status and electrolyte balance need to be assessed first. The American Academy of Pediatrics recommends the use of isotonic solutions with adequate potassium chloride and dextrose for maintenance IV fluids in children.

Choice B: Collect a stool sample from the toddler Collecting a stool sample can help identify the cause of the gastroenteritis. However, this is not the first step. The stool sample collection should be done using a clean, dry toilet hat or plastic wrap. But before this, the child’s hydration status needs to be assessed.

Choice C: Determine if the toddler is voiding The first action the nurse should take when using the nursing process is assessment. Therefore, checking if the toddler is voiding is the priority. This will help assess the child’s hydration status, which is critical in managing acute gastroenteritis.

Choice D: Request evaluation of the toddler’s serum electrolytes Requesting an evaluation of the toddler’s serum electrolytes is also important, but it’s typically done after the initial assessment. Fluid and electrolyte derangement are the immediate causes that increase the mortality in diarrhea. However, before requesting this evaluation, the nurse should first determine if the toddler is voiding to assess the child’s hydration status.

A. Lime ice pop B. Cranberry juice C. Ice cream D. Apple juice

Correct Answer is A

Explanation

Choice A rationale
An orange ice pop is a good choice because it is cold and soothing for the throat, and it is also clear liquid which is usually recommended after tonsillectomy.
Choice B rationale
Cranberry juice is not the best choice because it is acidic and can cause discomfort to the surgical site.
Choice C rationale
Ice cream is not recommended immediately after surgery because dairy products can increase mucus production which can lead to coughing and discomfort.
Choice D rationale
Apple juice is not the best choice because it is acidic and can cause discomfort to the surgical site.

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A child has had a cast placed on his left arm following a diagnosed fracture. Which actions should the nurse take? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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