A nurse is caring for an adolescent following the application of a plaster cast for a fractured right tibia. Which of the following actions should the nurse take?

Discourage the client from ambulating.

Use a hair dryer on a hot setting to dry the cast.

Keep the client’s leg in a dependent position.

Perform a neurovascular check of the lower extremities.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Discouraging the client from ambulating is not the best action. While it’s important to limit weight-bearing activities initially, movement is encouraged to promote circulation and prevent complications such as deep vein thrombosis.
Choice B rationale
Using a hair dryer on a hot setting to dry the cast is not recommended. Heat can cause the cast to dry out and crack, and it can also burn the skin.
Choice C rationale
Keeping the client’s leg in a dependent position is not advisable. This can lead to increased swelling and pain, and potentially delay healing.
Choice D rationale
Performing a neurovascular check of the lower extremities is the correct action. This involves assessing for pain, pallor, pulselessness, paresthesia, and paralysis. These checks are crucial for monitoring for complications such as compartment syndrome and ensuring the cast is not too tight.

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Correct Answer is D

Explanation

Choice A rationale
The incubation period for varicella, or chickenpox, is typically longer than 2 to 5 days. It usually ranges from 10 to 21 days.
Choice B rationale
An incubation period of 3 to 4 weeks is within the typical range for varicella. However, the average incubation period is usually around 14 to 16 days.
Choice C rationale
An incubation period of 7 to 10 days is shorter than the typical incubation period for varicella, which is usually around 14 to 16 days.
Choice D rationale
An incubation period of 2 to 3 weeks is within the typical range for varicella. The average incubation period is usually around 14 to 16 days.

A. Initiate isotonic fluids with 20 mEq/L potassium chloride. B. Collect a stool sample from the toddler. C. Determine if the toddler is voiding. D. Request evaluation of the toddler’s serum electrolytes.

Correct Answer is C

Explanation

The correct answer is (C) Determine if the toddler is voiding.

Choice A: Initiate isotonic fluids with 20 mEq/L potassium chloride. While it is important to maintain hydration in a child with acute gastroenteritis, initiating isotonic fluids with 20 mEq/L potassium chloride is not the first action a nurse should take. The child’s hydration status and electrolyte balance need to be assessed first. The American Academy of Pediatrics recommends the use of isotonic solutions with adequate potassium chloride and dextrose for maintenance IV fluids in children.

Choice B: Collect a stool sample from the toddler Collecting a stool sample can help identify the cause of the gastroenteritis. However, this is not the first step. The stool sample collection should be done using a clean, dry toilet hat or plastic wrap. But before this, the child’s hydration status needs to be assessed.

Choice C: Determine if the toddler is voiding The first action the nurse should take when using the nursing process is assessment. Therefore, checking if the toddler is voiding is the priority. This will help assess the child’s hydration status, which is critical in managing acute gastroenteritis.

Choice D: Request evaluation of the toddler’s serum electrolytes Requesting an evaluation of the toddler’s serum electrolytes is also important, but it’s typically done after the initial assessment. Fluid and electrolyte derangement are the immediate causes that increase the mortality in diarrhea. However, before requesting this evaluation, the nurse should first determine if the toddler is voiding to assess the child’s hydration status.

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A nurse is caring for an adolescent following the application of a plaster cast for a fractured right tibia. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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