A nurse is caring for a toddler who had a plaster spica cast applied 6 hr ago. Which of the following actions is the nurse's priority?
Check the color and temperature of the toddler's toes.
Apply cushioning to the edge of the cast using adhesive tape.
Use a fan to circulate air around the cast.
Reposition the toddler every 2 hr.
The Correct Answer is A
A. Checking the color and temperature of the toes helps assess for adequate circulation and potential complications like compartment syndrome.
B. Applying cushioning to the cast edges is important for comfort but is not the immediate priority.
C. Using a fan can help the cast dry faster but is not the priority action.
D. Repositioning the toddler is important to prevent pressure sores, but ensuring proper circulation takes precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Potential Condition: Increased intracranial pressure
Actions to Take:
Measure head circumference: This action is important to monitor for signs of increasing intracranial pressure, as a bulging and tense fontanel suggests possible hydrocephalus or other intracranial pathology.
Plan to assist with administration of antibiotics: Antibiotics may be necessary if there is suspected meningitis or another infectious cause contributing to increased intracranial pressure.
Parameters to Monitor:
Behavioral changes: Monitor for irritability, difficulty to console, and other behavioral changes which can indicate neurological distress.
Pupillary response: Assess for changes in pupillary size and reactivity, as altered pupillary responses can indicate neurological involvement and increased intracranial pressure.
Correct Answer is C
Explanation
A. Meperidine is not recommended for pain management in sickle cell crisis due to the risk of seizures and neurotoxicity. Fever should be managed with antipyretics like acetaminophen.
B. Increasing, not decreasing, daily oral fluid intake is important to help reduce blood viscosity and prevent further sickling of red blood cells.
C. Maintaining bed rest helps to reduce oxygen demand and prevent hypoxemia, which can exacerbate the vaso-occlusive crisis.
D. Applying cold compresses is not recommended as it can cause vasoconstriction and worsen the pain. Warm compresses are more appropriate for managing pain in sickle cell crisis.
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