A nurse is caring for a toddler who had a plaster spica cast applied 6 hr ago. Which of the following actions is the nurse's priority?
Check the color and temperature of the toddler's toes.
Apply cushioning to the edge of the cast using adhesive tape.
Use a fan to circulate air around the cast.
Reposition the toddler every 2 hr.
The Correct Answer is A
A. Checking the color and temperature of the toes helps assess for adequate circulation and potential complications like compartment syndrome.
B. Applying cushioning to the cast edges is important for comfort but is not the immediate priority.
C. Using a fan can help the cast dry faster but is not the priority action.
D. Repositioning the toddler is important to prevent pressure sores, but ensuring proper circulation takes precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Condition:
Pyelonephritis: The presence of fever, frequent and painful urination, and costovertebral angle tenderness, along with the urinalysis findings (cloudy urine, leukocyte esterase, nitrites, WBCs) and elevated WBC count suggest an upper urinary tract infection, likely pyelonephritis.
Actions to Take:
Request prescription for antibiotics: Pyelonephritis is a bacterial infection that requires antibiotic treatment to prevent complications and resolve the infection.
Encourage increased fluid intake: This helps to flush bacteria from the urinary tract, reducing the concentration of bacteria in the urine and helping to relieve symptoms.
Parameters to Monitor:
Child’s report of urgency: This can help assess if the infection is affecting the lower urinary tract as well and track the effectiveness of treatment.
Urine odor: Foul-smelling urine can indicate ongoing infection or bacterial presence and can be an indicator of the effectiveness of the treatment.
Correct Answer is B
Explanation
A. An increase in potassium levels is not directly related to the effectiveness of furosemide, which is a diuretic and can actually cause hypokalemia.
B. A decrease in edema indicates that the diuretic is effectively removing excess fluid from the body, which is a desired effect of furosemide in treating heart failure.
C. An increase in respiratory rate could indicate worsening heart failure or fluid overload, not the effectiveness of the medication.
D. A decrease in appetite is not a specific indication of the effectiveness of furosemide.
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