The nurse is caring for a 2-year-old patient. Which observation requires immediate action by the nurse?

The identification band has fallen off the patient's leg.

The IV fluid is 48 hours old.

The crib rails are halfway up.

The bed linen is damp.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

The identification band falling off the patient's leg is a documentation concern and doesn't require immediate action unless the patient is at risk of wandering or abduction.

Choice B rationale:

IV fluids should be changed every 24 hours to prevent bacterial growth and infection. Using fluids that are 48 hours old increases the risk of introducing infection to the patient.

Choice C rationale:

The crib rails being halfway up is not an immediate concern unless the child is at risk of falling or climbing out of the crib.

Choice D rationale:

Damp bed linen can be addressed during the next bedding change. It may not require immediate action unless the patient's skin integrity is at risk.

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Correct Answer is D

Explanation

Answer is d. Monitor the capillary refill time in the toes on both feet. This is crucial for assessing circulation and ensuring that the cast is not impairing blood flow, which is a priority in cast care.

Choice A rationale:

Ensuring the appropriate care for a wet plaster cast is essential to prevent complications such as impaired circulation, discomfort, or skin breakdown. Keeping the cast covered with a lightweight blanket, as suggested in option A, may seem like a logical step to protect it from external elements and maintain warmth. However, covering a wet cast can actually retain moisture, which can slow the drying process. Moisture retention within the cast can lead to prolonged drying times, increasing the risk of complications such as skin maceration or discomfort for the patient. Therefore, while the intention behind covering the cast is to provide comfort, it may inadvertently prolong the drying process and contribute to potential complications.

Choice B rationale:

Maintaining increased humidity in the patient room, as mentioned in option B, might appear beneficial to aid in the drying process of the plaster cast. However, while humidity can influence the drying time of the cast, excessive humidity can have adverse effects on the integrity of the cast. High humidity levels can prolong the drying process by inhibiting the evaporation of moisture from the cast material. Additionally, increased humidity can compromise the structural integrity of the cast, potentially leading to weaknesses or deformities. Therefore, while it's important to consider environmental factors in cast care, maintaining excessively high humidity levels may not be advisable and could contribute to complications in the drying and integrity of the cast.

Choice C rationale:

Option C suggests using only the tips of the fingers when handling the wet cast. While it's crucial to handle a wet cast with care to avoid causing damage or deformities, limiting handling to just the fingertips may not provide adequate support or control. Plaster casts can be fragile when wet, and improper handling techniques may lead to misshaping or weakening of the cast structure. Additionally, relying solely on the fingertips for handling may increase the risk of inadvertently applying uneven pressure or causing accidental damage to the cast material. Therefore, while the intention behind this option is to promote gentle handling, it may not provide sufficient support or control to ensure the integrity of the wet cast.

Choice D rationale:

Monitoring the capillary refill time in the toes on both feet, as indicated in option D, is the most appropriate action for the nurse to take in this scenario. Capillary refill time is a valuable indicator of peripheral circulation and tissue perfusion. By assessing the capillary refill time in the toes, the nurse can evaluate the adequacy of blood flow to the extremities and detect any potential impairment caused by the plaster hip spica cast. Prolonged capillary refill time may suggest compromised circulation, which can lead to serious complications such as ischemia or tissue necrosis if left unaddressed. Therefore, regular monitoring of capillary refill time is essential for early detection of circulation problems and timely intervention to ensure patient safety and optimal outcomes.

In conclusion, while each option may seem plausible at first glance, careful consideration of the potential implications reveals that monitoring capillary refill time in the toes on both feet is the most appropriate action for the nurse to take when caring for a patient with a wet plaster hip spica cast. This proactive approach prioritizes patient safety by ensuring adequate circulation and minimizing the risk of complications associated with impaired blood flow. By adhering to evidence-based practice guidelines and maintaining vigilance in monitoring patient status, healthcare professionals can optimize outcomes and promote the effective healing and management of patients with plaster casts.

A. The parent collects the specimen when the child reports itching. B. The parent collects the specimen in the evening before the child goes to bed. C. The parent collects the specimen after the child has had a bowel movement. D. The parent collects the specimen in the morning when the child awakens.

Correct Answer is D

Explanation

Choice A rationale:

The statement "The parent collects the specimen when the child reports itching”. is incorrect. The scotch tape test for pinworms involves placing clear tape on the perianal area in the morning to collect eggs that may have been laid during the night, not based on itching.

Choice B rationale:

The statement "The parent collects the specimen in the evening before the child goes to bed”. is incorrect. The test is most effective in the morning when the child wakes up, as this is when pinworms are most active and lay their eggs.

Choice C rationale:

The statement "The parent collects the specimen after the child has had a bowel movement”. is incorrect. The test doesn't involve collecting a specimen after a bowel movement but rather in the morning using transparent tape to catch pinworm eggs.

Choice D rationale:

The statement "The parent collects the specimen in the morning when the child awakens”. is correct. This is the correct time for the scotch tape test, as it maximizes the chance of detecting pinworm eggs laid during the night.

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The nurse is caring for a 2-year-old patient. Which observation requires immediate action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is placed in a plaster hip spica cast and is returned to the assigned room. The cast is still slightly wet. Which action by the nurse would be appropriate?

Correct Answer is D

Explanation

The nurse provides a parent with instructions on how to perform the scotch tape test to collect a specimen for ova and parasites in the perineal region of a child suspected of having pinworms. Which action by the parent indicates the test was done at the correct time?

Correct Answer is D

Explanation

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