The nurse is caring for a child who has had a unilateral long-leg cast applied for the correction of club foot.
What is the most important action for the nurse to perform?
Monitor the capillary refill of the toes.
Compare the temperature of both legs.
Observe for spontaneous movement.
Check the femoral pulses.
The Correct Answer is A
Choice A rationale
Monitoring the capillary refill of the toes is crucial when a child has a long-leg cast applied. This is because it helps assess the adequacy of circulation to the foot, which can be compromised by the cast. If the capillary refill is delayed (more than 2 seconds), it could indicate poor blood flow to the area, which could lead to serious complications such as tissue necrosis.
Choice B rationale
Comparing the temperature of both legs can provide information about circulation and inflammation. However, it is not the most important action in this case. While a significant difference in temperature could indicate a problem, it is not as direct an indicator of circulatory status as capillary refill.
Choice C rationale
Observing for spontaneous movement can provide information about nerve function. If the child is not moving the toes, it could indicate nerve damage. However, lack of movement could also be due to discomfort from the cast and is not as direct an indicator of circulatory status as capillary refill.
Choice D rationale
Checking the femoral pulses can provide information about circulation to the leg. However, the femoral pulse is proximal to the cast and may not accurately reflect circulation to the foot. Therefore, it is not the most important action in this case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["25"]
Explanation
Answer and explanation
Step 1 is to convert the child’s weight from pounds to kilograms since the dosage is prescribed in mg/kg. We know that 1 kg is approximately 2.2 lbs. So, the child’s weight in kg is 55 lbs ÷ 2.2 = 25 kg (rounded to the nearest whole number for simplicity).
Step 2 is to calculate the total daily dosage. The prescription is for isoniazid 10 mg/kg/day. So, the total daily dosage in mg is 10 mg/kg/day × 25 kg = 250 mg/day.
Step 3 is to calculate the volume of the oral solution to administer. The bottle is labeled, “Isoniazid Oral Solution, USP 50 mg per 5 mL.”. So, the volume in mL to administer is (250 mg/day ÷ 50 mg) × 5 mL = 25 mL. Therefore, the nurse should administer 25 mL of the Isoniazid Oral Solution, USP 50 mg per 5 mL, once a day.
Correct Answer is B
Explanation
Choice A rationale
While assessing parenting skills is important in general, in this specific situation, the parent has expressed a fear of needles which is preventing them from being able to administer the insulin injections. Therefore, assessing parenting skills would not directly address the issue at hand.
Choice B rationale
If the child is capable and comfortable with administering their own insulin injections, this could be a viable solution to the problem. It is not uncommon for children, especially those who are older or more mature, to take over the administration of their own insulin injections. Choice C rationale
Encouraging the parent to handle the needles may be helpful, but if the parent has a strong fear of needles, this may not be a feasible solution. It’s important to respect the parent’s fear and find alternative solutions.
Choice D rationale
Asking if there is someone else who can help with the injections could potentially be a solution, but it would depend on the family’s situation and whether there is another person who is willing and able to help.
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