A nurse is caring for a child who has a hip spica cast. Which of the following actions should the nurse take?
Place the child in a semi-sitting position for meals.
Maintain the child’s lower extremities in a dependent position.
Provide a bedside commode for toileting.
Turn the child every 2 hours.
The Correct Answer is D
Choice A reason: A semi-sitting position for meals is impractical in a hip spica cast, risking discomfort or aspiration; turning every 2 hours prevents pressure injuries. Assuming semi-sitting is correct risks complications, critical to avoid in ensuring safe positioning and care for children in spica casts.
Choice B reason: Maintaining dependent lower extremities increases edema risk in a hip spica cast; turning every 2 hours promotes circulation. Assuming dependent positioning is correct risks swelling, critical to prevent in ensuring proper cast care and comfort for children with hip spica casts.
Choice C reason: A bedside commode is unsuitable for a hip spica cast, which covers the pelvis; bedpans are used. Turning every 2 hours is key. Assuming a commode is appropriate risks impracticality, critical to avoid in ensuring proper toileting and care in spica cast management.
Choice D reason: Turning every 2 hours prevents pressure ulcers and promotes circulation in a child with a hip spica cast, critical for skin integrity and comfort. This ensures proper cast care, reducing complications, supporting healing, and maintaining safety in pediatric orthopedic management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: A temperature of 37.6°C is normal post-surgery, not requiring reporting; low urinary output is urgent. Assuming temperature is concerning risks overlooking renal issues, potentially delaying intervention, critical to avoid in ensuring comprehensive postoperative monitoring and client safety after abdominal surgery.
Choice B reason: Serous drainage is expected post-abdominal surgery, indicating normal healing, not requiring reporting. Low urinary output is priority. Assuming drainage is urgent risks misprioritizing, potentially neglecting renal complications, critical to prevent in ensuring proper postoperative care and recovery in surgical clients.
Choice C reason: Urinary output of 20 mL/hr is below normal (30-50 mL/hr), indicating potential renal impairment or dehydration post-surgery, requiring immediate reporting. This ensures timely intervention, critical for preventing kidney injury, maintaining fluid balance, and supporting recovery in clients post-abdominal surgery.
Choice D reason: Blood pressure of 100/70 mm Hg is low but not critical unless symptomatic; low urinary output is more urgent. Assuming blood pressure requires reporting risks overlooking renal issues, critical to avoid in ensuring prioritized monitoring and intervention in postoperative abdominal surgery clients.
Correct Answer is C
Explanation
Choice A reason: Wrapping sterile gauze for bleeding is inappropriate; gentle pressure and provider notification are needed. Petroleum jelly prevents adhesion. Using gauze risks infection or trauma, critical to avoid in ensuring safe circumcision healing, supporting parental care, and preventing complications in newborns post-procedure.
Choice B reason: Removing yellow exudate, a normal healing sign, risks disrupting the circumcision site, causing pain or infection. Petroleum jelly is correct. Assuming removal is needed risks delayed healing, critical to prevent in ensuring proper wound care and parental education for newborns post-circumcision.
Choice C reason: Applying petroleum jelly to the glans with diaper changes prevents diaper adhesion, promotes healing, and reduces discomfort post-circumcision. This instruction is critical for parental care, ensuring infection prevention, supporting newborn comfort, and facilitating proper healing in the sensitive post-procedure period.
Choice D reason: Using soap on the circumcision site risks irritation and delayed healing; gentle water cleansing is preferred. Petroleum jelly is appropriate. Assuming soap is safe risks discomfort or infection, critical to avoid in ensuring proper care and healing for newborns following circumcision procedures.
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