The nurse is continuing to care for the child.
For each statement by the parent, click to specify if the statement reflects an understanding or indicates a need for reinforcement of the discharge teaching.
"We should notify the provider if the cast becomes loose over time."
"It is important that our child avoids placing anything inside the cast."
"We should expect the swelling and tingling to worsen before it gets better."
"We need to be very careful about how we handle the cast for the first 2 days while it dries."
"We should prop the casted arm on pillows for the next 24 hours."
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}
Rationale:
- "We should notify the provider if the cast becomes loose over time." A loose cast may no longer immobilize the fracture effectively and can allow excessive movement. It may also rub the skin, increasing the risk of irritation or breakdown.
- "It is important that our child avoids placing anything inside the cast." This statement reflects understanding because inserting objects inside the cast can break the skin and introduce bacteria, leading to infection. It may also damage the padding and compromise skin protection.
- "We should expect the swelling and tingling to worsen before it gets better." This statement needs reinforcement because worsening swelling and tingling can indicate early signs of compartment syndrome. These symptoms are not normal and should prompt immediate medical attention.
- "We need to be very careful about how we handle the cast for the first 2 days while it dries." This shows understanding because a plaster cast takes 24 to 48 hours to fully dry. Improper handling can cause pressure indentations, leading to skin damage and poor cast integrity
- "We should prop the casted arm on pillows for the next 24 hours." Elevating the limb helps reduce swelling and pain by improving venous return. Keeping the casted arm elevated is a standard part of cast care teaching after an injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. “I should advise a client about what I feel to be his best health care decision.": Advocacy involves supporting the client’s choices and rights, not imposing the nurse’s personal opinions. Advising based on personal beliefs undermines the client’s autonomy and is not consistent with professional advocacy.
B. "I should not advocate for a client unless he is able to ask me himself.": Client advocacy includes speaking up on behalf of clients who cannot voice their own needs, such as those who are incapacitated or vulnerable. Waiting for the client to ask would neglect the nurse’s responsibility to protect and support the client.
C. “I will intervene if there is a conflict between a client and his provider.": Advocacy involves intervening when a client’s rights, preferences, or safety are at risk, including resolving conflicts with providers. This demonstrates understanding of the nurse’s role in ensuring the client’s voice is heard and needs are met.
D. “I will inform a client that his family should help make his health care decisions.": While family input can be important, the client’s autonomy takes priority. Encouraging family decision-making over the client’s choices does not reflect proper advocacy and may compromise the client’s rights.
Correct Answer is C
Explanation
Rationale:
A. WBC count 10,000/mm³ (5,000 to 10,000/mm³): This value is at the upper limit of normal. Mild elevations can occur during early pregnancy due to physiological changes and do not typically require immediate reporting unless accompanied by signs of infection.
B. Fasting blood glucose 80 mg/dL (74 to 106 mg/dL): This value falls within the normal fasting glucose range for adults and is not concerning during early pregnancy. No intervention or reporting is necessary for this result.
C. Hematocrit 30% (37% to 47%): This value is below the normal range, indicating anemia. Early pregnancy anemia can increase the risk of maternal fatigue, preterm birth, and low birth weight. The nurse should report this finding to the provider for further evaluation and possible iron supplementation.
D. RBC count 6 million/mm³ (4.2 to 6.1 million/mm³): This value is within the normal range for red blood cells. It does not indicate any immediate concern and does not require reporting to the provider.
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