What would be included in the plan of care for a child just returned to the floor from surgery in which a clubfoot was repaired? Select all that apply.
Observe for skin irritation.
Keep cast uncovered to allow drying.
Assess color of toes.
Check toes for capillary refill.
Keep casted leg lowered.
Correct Answer : A,B,C,D
The correct answer is A, B, C, and D. After a clubfoot repair surgery, the plan of care should include observing for skin irritation, keeping the cast uncovered to allow drying, assessing the color of toes, and checking toes for capillary refill. Keeping the casted leg lowered is not recommended as it can lead to swelling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["6"]
Explanation
Step 1 is to set up the equation to solve for the unknown, which is the volume in mL. The equation is (300 mg ÷ 250 mg) × 5 mL.
Step 2 is to perform the calculation: (300 mg ÷ 250 mg) × 5 mL = 6 mL. So, the nurse should administer 6 mL of amoxicillin oral solution.
Correct Answer is A
Explanation
Choice A rationale
A bulging fontanel is a common sign of increased intracranial pressure (ICP) in infants. The fontanels, or soft spots on an infant’s head, allow for brain growth. When there is increased pressure, as in conditions that cause increased ICP, it can cause the fontanels to bulge outwards.
Choice B rationale
Insomnia is not typically associated with increased ICP in infants. Changes in consciousness, such as irritability or lethargy, may be seen, but these are not the same as insomnia.
Choice C rationale
A low-pitched cry is not typically associated with increased ICP in infants. Changes in cry might occur, but they are not specific to increased ICP4.
Choice D rationale
A positive Babinski reflex is normal in infants up to about 12 months of age. It is not specifically associated with increased ICP4.
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