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 C
Explanation
A. Instilling 2 mL of 0.9% sodium chloride is not recommended as it can cause discomfort and does not improve the effectiveness of suctioning.
B. Sterile technique, not clean technique, should be used when suctioning a tracheostomy to prevent infection.
C. Applying suction in 3 to 4 second increments is appropriate to clear the occlusion effectively without causing trauma to the trachea.
D. The catheter should not fit snugly into the tracheostomy tube; it should be small enough to fit comfortably to avoid trauma and ensure effective suctioning.
Correct Answer is D
Explanation
A. Restricting fluid intake is not recommended; instead, increasing fluids helps flush out the contrast dye used during the procedure and aids in kidney function.
B. Children typically can return to school within a few days to a week, not 3 to 4 weeks, unless otherwise directed by the physician. Prolonged absence is generally unnecessary unless complications arise.
C. The catheterization site should not have drainage for 3 to 5 days. Any drainage could indicate an infection or other complication and should be evaluated by a healthcare provider.
D. Avoiding baths for the first 3 days helps prevent infection at the catheterization site. Sponge baths are recommended to keep the site clean and dry during the initial healing period.
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