A nurse is caring for a client with a plaster hip spica cast. What measure would best protect the cast from being soiled by urine and feces?
Tuck small disposable diapers under the cast edges in the buttock area.
Line the edges of the cast with absorbent pads and secure with tape.
Place a large cloth diaper over the perineal cutout area.
Lay the client on a disposable pad with the perineal area exposed to air.
The Correct Answer is C
Choice A rationale:
Tucking small disposable diapers under the cast edges in the buttock area may cause discomfort to the patient and could also potentially disrupt the cast alignment. It may also not effectively prevent soiling.
Choice B rationale:
Lining the edges of the cast with absorbent pads and securing with tape might not fully protect the cast from urine and feces. The absorbent pads could still allow some leakage and contamination.
Choice C rationale:
Placing a large cloth diaper over the perineal cutout area provides comprehensive protection against urine and feces soiling the cast. This method ensures that the cast remains clean and dry.
Choice D rationale:
Laying the client on a disposable pad with the perineal area exposed to air is not a practical solution. It does not offer adequate protection for the cast, and exposing the perineal area to air could lead to discomfort and potential complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale:
After cleft palate repair, infants should be fed pureed or soft foods to prevent trauma to the surgical site and facilitate healing. These textures minimize the risk of injury and avoid strain on the repaired area.
Choice A rationale:
Allowing the child to self-feed with a spoon can introduce solid textures prematurely and pose a risk of disrupting the surgical repair.
Choice C rationale:
Using a cup with a straw might cause suction that could negatively impact the healing surgical site, increasing the risk of complications.
Choice D rationale:
Restricting breastfeeding is not necessary for cleft palate repair. However, positioning adjustments may be needed to facilitate effective breastfeeding while minimizing stress on the surgical area.
Correct Answer is D
Explanation
Choice A rationale:
Ketonuria is the presence of ketones in urine and is not directly associated with vaso-occlusive crisis in sickle cell anemia. This crisis typically involves pain and ischemia in various body parts.
Choice B rationale:
Diplopia refers to double vision and is not a typical symptom of vaso-occlusive crisis. Pain, not vision changes, is the primary concern in this scenario.
Choice C rationale:
Severe abdominal pain can be a symptom of vaso-occlusive crisis in sickle cell anemia, but the patient's complaint of left elbow pain would not directly correlate with this choice.
Choice D rationale:
Hyperactive patellar reflex is the correct answer. During vaso-occlusive crisis, the body's response to pain can lead to increased muscle tone and reflexes, including hyperactive deep tendon reflexes like the patellar reflex. This is an indicator of neurologic involvement in the crisis. Remember that these rationales are intended to provide a concise understanding of the correct answers based on the information provided in the questions. Always refer to medical literature and consult with healthcare professionals for comprehensive and accurate information.
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