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 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.
Correct Answer is A
Explanation
Choice A rationale
Activated charcoal is often used in the management of poisoning. It works by binding to the poison in the stomach and preventing it from being absorbed into the body14.
Choice B rationale
Osmotic diarrheal agents are not typically used in gastric lavage. These agents work by increasing the amount of water in the intestinal tract, which can stimulate bowel movements14.
Choice C rationale
Syrup of ipecac was once used to induce vomiting in cases of poisoning, but it is no longer recommended for use in poisoning cases14.
Choice D rationale
0.9% sodium chloride, or normal saline, is a type of fluid that’s often used in medical treatments, but it’s not typically used in gastric lavage for poisoning14.
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