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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While maintaining a saline-lock can be important for administering medications or fluids, it is not the priority action. The nurse’s priority should be to assess the child’s condition and intervene to prevent complications.
Choice B rationale
A no-salt-added diet may be recommended for some children with acute glomerulonephritis to help manage fluid balance and blood pressure. However, this is not the priority action. The nurse’s priority should be to assess the child’s condition and intervene to prevent complications.
Choice C rationale
This is the correct answer. Checking the child’s weight daily is a priority action because weight changes can indicate fluid retention or loss, which can affect kidney function. Regular weight checks can help guide treatment decisions and monitor the effectiveness of interventions.
Choice D rationale
Educating the parents about potential complications is important, but it is not the priority action. The nurse’s priority should be to assess the child’s condition and intervene to prevent complications.
Correct Answer is C
Explanation
Choice A rationale
While it’s true that bone marrow can be lost through a fracture, this is not specific to fractures of the epiphyseal plate.
Choice B rationale
The healing time for fractures in children and adults can vary depending on many factors, but it’s not accurate to say that fractures in children take longer to heal than fractures in adults.
Choice C rationale
Normal bone growth can indeed be affected by a fracture of the epiphyseal plate. The epiphyseal plate, or growth plate, is the area of growing tissue near the ends of the long bones in children and adolescents. When a fracture occurs at the epiphyseal plate, it can disrupt the normal growth of the bone and lead to deformities.
Choice D rationale
While calcium is important for bone health, increasing a child’s calcium intake to 3,000 milligrams daily is not typically recommended as part of the treatment or management of a fracture.
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