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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Strict isolation should begin immediately after exposure. This choice is incorrect because chickenpox does not require strict isolation immediately after exposure. The incubation period of chickenpox is about 10-21 days, during which communicability has not yet begun.

Choice B rationale:

Communicability begins prior to the eruption of lesions. This choice is correct. Chickenpox is highly contagious, and individuals can transmit the virus to others even before the characteristic skin lesions appear. This understanding is crucial for appropriate room assignment to prevent the spread of the virus to other patients.

Choice C rationale:

Strict isolation should begin as soon as the skin lesions erupt. This choice is incorrect. While isolation precautions are necessary for patients with active chickenpox lesions, waiting until the lesions erupt is not sufficient to prevent transmission, as communicability starts before this stage.

Choice D rationale:

Communicability begins 14 days after exposure. This choice is incorrect. The correct timing for the onset of communicability is much earlier than 14 days after exposure. Waiting until this point for isolation would not effectively prevent transmission.

A. Have a child life specialist explain the procedure using a doll. B. Give the client color handouts explaining the procedure. C. Tell the client that a lot of children have this procedure. D. Allow the patient to watch a video of the procedure on another child.

Correct Answer is A

Explanation

Have a child life specialist explain the procedure using a doll.

Choice A rationale:

Having a child life specialist explain the procedure using a doll is the best approach for preparing a 4-year-old for a bone marrow aspiration. This method utilizes play therapy to help the child understand the procedure in a developmentally appropriate and non-threatening way.

Choice B rationale:

Giving the client color handouts might not effectively engage a 4-year-old's attention and understanding. Young children often benefit more from interactive and visual methods like using a doll.

Choice C rationale:

Telling the client that other children have had the procedure might not alleviate the child's anxiety or fear. Concrete explanations and visual aids are more effective in reducing anxiety and helping the child cope.

Choice D rationale:

Allowing the patient to watch a video of the procedure on another child could potentially increase anxiety and fear. Children might not fully comprehend the video and could misinterpret it, leading to more distress. Interactive methods are more effective.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When admitting a 4-year-old patient to the hospital, the nurse learns that the child was exposed to chicken pox three days ago. Which understanding about chicken pox should the nurse consider during room assignment?

Correct Answer is B

Explanation

Which nursing action is the best way to prepare a 4-year-old client for a bone marrow aspiration?

Correct Answer is A

Explanation

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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?