A child has had a cast placed on his left arm following a diagnosed fracture. Which actions should the nurse take? (Select all that apply)
Smooth the rough edges of the cast to maintain skin integrity
Wear sterile gloves when touching or removing the cast
Monitor capillary refill and color of nail beds of the left-hand
Monitor for signs of pain
Assess for numbness, tingling, or decreased sensation of the left hand.
Correct Answer : A,C,D,E
Choice A rationale
Smoothing the rough edges of the cast can help maintain skin integrity and prevent skin irritation or injury.
Choice C rationale
Monitoring capillary refill and color of nail beds of the left hand is important to assess the circulation to the hand and ensure that the cast is not too tight.
Choice D rationale
Monitoring for signs of pain can help detect complications such as compartment syndrome, which is a serious condition that can occur if pressure within the muscles builds to dangerous levels.
Choice E rationale
Assessing for numbness, tingling, or decreased sensation of the left hand is important as these can be signs of nerve damage or compression.
Choice B rationale
Wearing sterile gloves when touching or removing the cast is not typically necessary. The outside of a cast is not a sterile environment, and healthcare providers do not usually wear sterile gloves when handling it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Projectile vomiting is a common symptom in infants with pyloric stenosis. This is due to the narrowing of the pylorus, the muscular valve at the bottom of the stomach, which prevents breast milk or formula from passing through to the small intestine.
Choice B rationale
Effortless regurgitation is not typically associated with pyloric stenosis. The hallmark symptom of pyloric stenosis is projectile vomiting.
Choice C rationale
Metabolic acidosis is not a typical symptom of pyloric stenosis. The hallmark symptom of pyloric stenosis is projectile vomiting.
Choice D rationale
While a distended abdomen can occur in some cases of pyloric stenosis, it is not the most common symptom. The hallmark symptom of pyloric stenosis is projectile vomiting.
Correct Answer is C
Explanation
Choice A rationale
Administering syrup of ipecac is not recommended in cases of iron overdose. Ipecac was once used to induce vomiting in cases of poisoning, but it is no longer recommended due to potential complications and lack of evidence for effectiveness.
Choice B rationale
Giving the child orange juice will not help in this situation. While vitamin C can enhance iron absorption, it does not have an effect on iron that has already been absorbed into the body.
Choice C rationale
Contacting the poison control center is the appropriate action. They can provide immediate advice on what to do in cases of potential iron overdose.
Choice D rationale
Providing a high-carbohydrate snack will not help in this situation. It will not affect the absorption or toxicity of the iron.
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