A nurse is reinforcing teaching with the parent of a preschooler who has a hip fracture and is in a spica cast. Which of the following findings should the nurse identify as an indication of infection?
Hot spot on the cast
General edema of the toes
Pruritus under the cast
Pain at the fracture site
The Correct Answer is A
A. A hot spot on the cast may indicate localized infection. When the skin underneath the cast becomes infected, it can lead to localized warmth, tenderness, and redness. It is important to promptly assess and address the situation, as infections can progress quickly in these circumstances.
B. General edema of the toes is a common response to immobilization and injury, but it does not specifically indicate infection. It is more likely related to inflammation or impaired circulation from the cast.
C. Pruritus (itching) under the cast can occur due to the skin's reaction to the cast material, dryness, or moisture accumulation, but it is not necessarily an indication of infection.
D. Pain at the fracture site is common and expected as the fracture heals, but it alone is not an indication of infection unless associated with other symptoms like fever, warmth, or drainage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Selecting a catheter that fits snugly is important for proper suctioning, but it is more important to ensure the catheter is the correct size for the infant’s tracheostomy tube and airway.
B. Instilling saline prior to suctioning is generally not recommended unless specified by the healthcare provider, as it can increase the risk of aspiration and discomfort.
C. Suctioning should be done in short 3 to 4 second increments to avoid injury to the airway and to minimize the infant’s distress. Prolonged suctioning can cause hypoxia and trauma to the mucosa.
D. Suctioning for infants with tracheostomies requires sterile technique to prevent infection, not clean technique.
Correct Answer is B
Explanation
A. Neck flexion when bending forward is not a typical indicator of scoliosis. Scoliosis is identified by abnormal curvature of the spine, not by the neck.
B. Uneven shoulders when standing erect are a key indicator of scoliosis. This asymmetry can be identified when the child bends forward at the waist, which is a standard test for scoliosis during a physical examination.
C. Toes that point inward when bending forward is not a sign of scoliosis. This could be indicative of a different musculoskeletal issue such as hip or leg alignment problems, but it is not related to scoliosis.
D. Knees that bow outward when standing erect indicate bow-leggedness (genu varum), not scoliosis. Scoliosis specifically affects the spine's curvature.
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