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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale:

Children with nephrotic syndrome are at an increased risk of infection due to loss of immunoglobulins and other immune-related proteins in the urine, along with the use of immunosuppressive medications. The proteinuria associated with nephrotic syndrome leads to hypoalbuminemia and decreased immunity, making the child susceptible to infections, particularly bacterial peritonitis. Preventive measures include proper hand hygiene, maintaining a clean environment, and timely administration of prescribed antibiotics.

Choice B rationale:

Hypertension is not a primary complication of nephrotic syndrome in children. While they may have fluid retention and edema, resulting in increased blood pressure, infection is a more significant concern.

Choice C rationale:

Weight loss is not a typical complication of nephrotic syndrome but rather the opposite. Children with nephrotic syndrome often experience weight gain due to fluid retention and edema.

Choice D rationale:

Hyperkalemia is a possible electrolyte imbalance in nephrotic syndrome, but it is not a primary concern for children with this condition. The loss of protein in the urine can lead to hypoalbuminemia and subsequent edema, but hyperkalemia is not a common initial complication.

A. An increasing pulse rate. B. Mouth breathing. C. An increase in nasal discharge. D. A hoarse cry.

Correct Answer is A

Explanation

Choice A rationale:

An increasing pulse rate suggests that the patient's condition is worsening. Tachycardia can indicate increased work of breathing and decreased oxygenation, which are concerning signs in laryngotracheobronchitis.

Choice B rationale:

Mouth breathing is a common response to airway obstruction, such as in laryngotracheobronchitis. While it indicates respiratory distress, it doesn't specifically suggest a worsening of the condition.

Choice C rationale:

An increase in nasal discharge might be seen with the common cold or other upper respiratory infections but is not a specific indicator of worsening laryngotracheobronchitis.

Choice D rationale:

A hoarse cry is a characteristic symptom of laryngotracheobronchitis due to inflammation of the airway. However, it is a common initial symptom and may not directly correlate with worsening of the condition.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An 8-year-old who is receiving treatment for nephrotic syndrome should have a plan of care for the reduction of the risk for which complication?

Correct Answer is A

Explanation

A patient is admitted from the emergency room with laryngotracheobronchitis. The patient has a brassy cough, stridor, and substernal retractions. The child is receiving an intravenous infusion and is placed in a mist tent. Which observation would indicate a worsening of the patient's condition?

Correct Answer is A

Explanation

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