A nurse is caring for a client with a plaster hip spica cast. What measure would best protect the cast from being soiled by urine and feces?
Tuck small disposable diapers under the cast edges in the buttock area.
Line the edges of the cast with absorbent pads and secure with tape.
Place a large cloth diaper over the perineal cutout area.
Lay the client on a disposable pad with the perineal area exposed to air.
The Correct Answer is C
Choice A rationale:
Tucking small disposable diapers under the cast edges in the buttock area may cause discomfort to the patient and could also potentially disrupt the cast alignment. It may also not effectively prevent soiling.
Choice B rationale:
Lining the edges of the cast with absorbent pads and securing with tape might not fully protect the cast from urine and feces. The absorbent pads could still allow some leakage and contamination.
Choice C rationale:
Placing a large cloth diaper over the perineal cutout area provides comprehensive protection against urine and feces soiling the cast. This method ensures that the cast remains clean and dry.
Choice D rationale:
Laying the client on a disposable pad with the perineal area exposed to air is not a practical solution. It does not offer adequate protection for the cast, and exposing the perineal area to air could lead to discomfort and potential complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
This response acknowledges the client's feelings, addresses the immediate situation, and offers an alternative without judgment.
Choice B rationale:
Asking "What's wrong? Haven't you ever lost a game before?”. might come across as dismissive and insensitive to the client's emotions.
Choice C rationale:
Simply saying "I am sure you'll win the next game”. minimizes the client's feelings and does not address the current situation.
Choice D rationale:
Telling the client that "other children will not want to play with you if you act like that”. is a negative and shaming response, which is counterproductive to building a therapeutic relationship.
Correct Answer is B
Explanation
Choice A rationale:
Allowing the patient to stay in the chosen position might not be the best approach, as the child's preference might not align with therapeutic considerations for managing status asthmaticus.
Choice B rationale:
Semi-Fowler's position, with the head of the bed elevated, promotes improved lung expansion and easier breathing for patients with respiratory distress. Explaining the rationale behind this position to the child helps them understand its therapeutic benefits, encouraging compliance.
Choice C rationale:
Demonstrating various positions could confuse the child and delay appropriate intervention. A clear explanation of the preferred position is more effective in this critical situation.
Choice D rationale:
Removing pillows might be counterproductive, as elevating the head of the bed is beneficial for respiratory distress. This choice contradicts the therapeutic goal.
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