A 5-year-old with an arm cast from a fractured wrist complains of itching under his cast. The nurse knows cast care teaching for the parent has been successful when the parent states:
I can use a cool air dryer to help circulate air to relieve the itch.
I can use a hot air dryer to help circulate air to relieve the itch.
"I can use a damp towel to trickle water into the cast to relieve the Itch."
"I can use a plastic hanger to slide into the cast to relieve the Itch."
The Correct Answer is A
This statement demonstrates an understanding of proper cast care for itch relief. Using a cool air dryer on a low setting can help circulate air and provide relief from itching under the cast. It is important not to use a hot air dryer as it may cause discomfort, skin irritation, or burn. Trickling water or inserting objects into the cast can lead to moisture accumulation and potential complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
The initial bundle of care in sepsis includes the following:
- Obtain blood cultures: Blood cultures help identify the specific microorganism causing the infection, which is important for guiding appropriate antibiotic therapy.
- Administer broad-spectrum antibiotics: Early administration of antibiotics is crucial in sepsis to target the suspected or likely infectious organisms. Broad-spectrum antibiotics cover a wide range of potential pathogens until more specific information from culture results is available.
- Obtain lactate levels: Measuring lactate levels helps assess tissue perfusion and can be used as an indicator of the severity of sepsis. Elevated lactate levels are associated with tissue hypoperfusion and increased mortality.
- Administer IV fluid bolus: Early aggressive fluid resuscitation is an essential component of sepsis management. Administering intravenous fluids helps restore intravascular volume and improve tissue perfusion.
- Administration of vasopressors: Especially in the setting of hypotension and to maintain MAP above 65mmHg.
Correct Answer is A
Explanation
Anaphylaxis is a severe and potentially life-threatening allergic reaction that can lead to a rapid drop in blood pressure, known as hypotension. This drop in blood pressure is a critical indicator of the severity of the reaction and the effectiveness of the treatment provided. The nurse needs to monitor the patient's blood pressure closely to ensure it stabilizes and returns to a safe range.
While oxygen saturation, heart rate, and orientation are also important parameters to assess, they are secondary to blood pressure in evaluating the effectiveness of treatment for anaphylaxis. Oxygen saturation can help determine the adequacy of oxygenation, heart rate can indicate the presence of tachycardia (which may be a sign of an ongoing reaction or hypoperfusion), and orientation can provide information about the patient's mental status and potential complications.
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