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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Abdominal rigidity and pain on palpation are not typical signs of pyloric stenosis. Pyloric stenosis usually presents with non-bilious projectile vomiting, a palpable olive-shaped mass in the upper abdomen, and signs of dehydration.
Choice B rationale:
A rounded abdomen and hypoactive bowel sounds are characteristic signs of pyloric stenosis. The hypertrophied pyloric muscle obstructs the passage of food from the stomach to the duodenum, leading to gastric distention, visible peristalsis, and vomiting. The infant may appear hungry after vomiting and will continue to feed, leading to weight loss.
Choice C rationale:
Visible peristalsis and weight loss are consistent with pyloric stenosis. The visible peristalsis occurs as the infant tries to force the stomach contents through the narrowed pyloric sphincter. Weight loss is a result of poor feeding and vomiting.
Choice D rationale:
Distention of the lower abdomen and constipation are not typical findings in pyloric stenosis. Constipation suggests a lower gastrointestinal issue, while pyloric stenosis primarily affects the upper gastrointestinal tract.
Correct Answer is D
Explanation
Choice A rationale
Rapid respirations are not typically a manifestation of hypoglycemia. They are more commonly associated with conditions that cause metabolic acidosis, such as diabetic ketoacidosis.
Choice B rationale
Diminished reflexes are not a typical manifestation of hypoglycemia. They may be seen in conditions affecting the nervous system.
Choice C rationale
Acetone breath is not a manifestation of hypoglycemia. It is a sign of ketoacidosis, which is a complication of hyperglycemia, not hypoglycemia.
Choice D rationale
Diaphoresis, or sweating, is a common symptom of hypoglycemia. The body produces sweat as part of the sympathetic nervous system’s response to hypoglycemia.
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