A nurse is reinforcing teaching with the parent of a preschooler who has a hip fracture and is in a spica cast.Which of the following findings should the nurse identify as an indication of infection?
Hot spot on the cast.
Pruritus under the cast.
General edema of the toes.
Pain at the fracture site.
The Correct Answer is A
Choice A rationale
A hot spot on the cast indicates localized warmth, which is a common sign of infection. The presence of a hot spot suggests that there might be an underlying infection beneath the cast, potentially requiring medical intervention. It is important to monitor for signs of infection to prevent complications and ensure proper healing of the fracture.
Choice B rationale
Pruritus, or itching, under the cast is a common discomfort experienced by patients with casts. It is usually due to dry skin or irritation but is not typically a sign of infection. While pruritus can be bothersome, it does not indicate an infectious process and can be managed with appropriate skin care.
Choice C rationale
General edema of the toes can occur due to prolonged immobility or dependency of the limb. While it can indicate impaired circulation or venous return, it is not specific to infection. Generalized edema requires monitoring but is not a definitive sign of infection within the cast.
Choice D rationale
Pain at the fracture site is expected after a fracture and can be managed with analgesics and proper cast care. Persistent or worsening pain might indicate complications such as improper cast fit or delayed healing, but it is not a specific sign of infection. Pain management and follow-up are essential for recovery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Massaging the injection site after administering a vaccine is generally not recommended as it may cause irritation or introduce bacteria to the site, increasing the risk of infection. Additionally, massaging the area does not improve the absorption or efficacy of the vaccine. Vaccines are designed to be absorbed effectively by the body without the need for additional manipulation. Healthcare professionals are trained to administer vaccines using techniques that minimize discomfort and ensure proper delivery of the vaccine into the muscle tissue.
Choice B rationale
Aspiration, or pulling back on the syringe plunger after inserting the needle but before injecting the vaccine, is not recommended when administering vaccines. Studies have shown that aspiration is unnecessary and may increase the risk of injury, pain, and prolonged injection time. The practice of aspiration is based on the outdated concern of inadvertently injecting the vaccine into a blood vessel. However, research indicates that the risk of this occurring is extremely low when proper injection techniques are used. The focus should be on delivering the vaccine quickly and efficiently to minimize discomfort.
Choice C rationale
Ensuring that the guardian has signed a consent form for immunization is an essential step in the vaccination process. Obtaining informed consent means that the guardian is aware of the potential benefits and risks associated with the vaccine and agrees to proceed with the vaccination. This practice is crucial for maintaining trust between healthcare providers and patients, respecting the rights of individuals to make informed healthcare decisions, and adhering to legal and ethical standards in medical practice. Proper documentation of consent is also important for record-keeping and future reference.
Correct Answer is A
Explanation
Choice A rationale
Clostridium difficile requires contact precautions because it spreads through direct contact with contaminated surfaces or infected individuals. The organism produces spores that can survive on surfaces for long periods, making it highly contagious. Contact precautions help prevent the transmission by using protective equipment such as gloves and gowns and ensuring proper hand hygiene with soap and water.
Choice B rationale
Streptococcal pharyngitis, also known as strep throat, primarily spreads through respiratory droplets rather than direct contact. Therefore, contact precautions are not typically required.
Choice C rationale
Haemophilus influenzae spreads through respiratory droplets rather than direct contact. Droplet precautions are more appropriate to prevent its transmission, rather than contact precautions.
Choice D rationale
Mycoplasma pneumoniae also spreads through respiratory droplets and does not typically require contact precautions. Droplet precautions are more suitable for preventing its transmission.
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