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 A

Explanation

Choice A rationale
The first action a nurse should take upon finding a school-age child having a seizure is to ease the person to the floor and turn the person gently onto one side. This will help the person breathe and can prevent injury.
Choice B rationale
Administering an anticonvulsant medication is not the immediate first action a nurse should take upon finding a child having a seizure. The first priority is to ensure the child’s safety by easing them to the floor and turning them onto their side.
Choice C rationale
Applying oxygen by nasal cannula is not the immediate first action a nurse should take upon finding a child having a seizure. The first priority is to ensure the child’s safety by easing them to the floor and turning them onto their side.
Choice D rationale
Checking the client’s oxygen saturation is not the immediate first action a nurse should take upon finding a child having a seizure. The first priority is to ensure the child’s safety by easing them to the floor and turning them onto their side.

A. A child who received a blood transfusion 1 month ago. B. A child currently receiving immunoglobulins. C. A child currently receiving chemotherapy. D. A child who has a cold and nasal discharge.

Correct Answer is D

Explanation

Choice A rationale
A child who received a blood transfusion 1 month ago is not recommended to receive the varicella vaccine. This is because blood transfusions can introduce new antibodies into the body that may interfere with the immune response to the vaccine.
Choice B rationale
A child currently receiving immunoglobulins should not receive the varicella vaccine. Immunoglobulins are proteins in the blood that function as antibodies. They can interfere with the body’s immune response to the vaccine.
Choice C rationale
A child currently receiving chemotherapy should not receive the varicella vaccine. Chemotherapy can weaken the immune system, making it less effective at responding to vaccines.
Choice D rationale
A child who has a cold and nasal discharge can receive the varicella vaccine. Mild illnesses, such as a cold, do not interfere with the immune response to the vaccine.

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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

Upon finding a school-age child having a seizure, what should be the nurse’s first action after lowering the client to the floor?

Correct Answer is A

Explanation

A nurse is providing care to a group of children at a pediatric clinic. Which of the following children meets the criteria to receive a varicella vaccine?

Correct Answer is D

Explanation

The nurse is caring for an infant with suspected pyloric stenosis. Which clinical manifestation would indicate pyloric stenosis?

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