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 A
Explanation
A.Infants with HF tire easily; feeding them early, before they are overly fatigued and crying, conserves energy and helps them take in more nutrition. Smaller, more frequent feedings are often recommended.
B. A firm nipple may require more effort to suck, which can be tiring for an infant with heart failure. A softer nipple may be more appropriate.
C. Diluting the formula with water can lead to inadequate caloric intake and nutritional deficiencies. Formula should be prepared according to instructions to ensure proper nutrition.
D. Thickened feeds are sometimes used for reflux, not HF. Adding cereal increases caloric intake but also makes sucking/swallowing more difficult, increasing energy expenditure.
Correct Answer is B
Explanation
A. Polyuria is not typically associated with sepsis; it may be seen in other conditions such as diabetes. In sepsis, urine output is often decreased due to impaired kidney function and shock.
B. Disorientation is a sign of sepsis, indicating that the infection may have spread to the bloodstream and is affecting the central nervous system. Altered mental status is a critical indicator of severe infection.
C. Hyperactive bowel sounds are not associated with sepsis. In sepsis, bowel sounds may actually be decreased due to decreased perfusion to the gastrointestinal tract.
D. Hypoglycemia can occur in sepsis, but it is not as specific an indicator as disorientation. Monitoring blood glucose levels is important, but disorientation provides a clearer sign of systemic infection.
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