A patient is placed in a plaster hip spica cast and is returned to the assigned room. The cast is still slightly wet. Which action by the nurse would be appropriate?

Keep the cast covered with a light-weight blanket.

Maintain increased humidity in the patient room.

Use only the tips of the fingers when handling the cast.

Monitor the capillary refill time in the toes on both feet.

Answer and Explanation

The Correct Answer is D

Answer is d. Monitor the capillary refill time in the toes on both feet. This is crucial for assessing circulation and ensuring that the cast is not impairing blood flow, which is a priority in cast care.

Choice A rationale:

Ensuring the appropriate care for a wet plaster cast is essential to prevent complications such as impaired circulation, discomfort, or skin breakdown. Keeping the cast covered with a lightweight blanket, as suggested in option A, may seem like a logical step to protect it from external elements and maintain warmth. However, covering a wet cast can actually retain moisture, which can slow the drying process. Moisture retention within the cast can lead to prolonged drying times, increasing the risk of complications such as skin maceration or discomfort for the patient. Therefore, while the intention behind covering the cast is to provide comfort, it may inadvertently prolong the drying process and contribute to potential complications.

Choice B rationale:

Maintaining increased humidity in the patient room, as mentioned in option B, might appear beneficial to aid in the drying process of the plaster cast. However, while humidity can influence the drying time of the cast, excessive humidity can have adverse effects on the integrity of the cast. High humidity levels can prolong the drying process by inhibiting the evaporation of moisture from the cast material. Additionally, increased humidity can compromise the structural integrity of the cast, potentially leading to weaknesses or deformities. Therefore, while it's important to consider environmental factors in cast care, maintaining excessively high humidity levels may not be advisable and could contribute to complications in the drying and integrity of the cast.

Choice C rationale:

Option C suggests using only the tips of the fingers when handling the wet cast. While it's crucial to handle a wet cast with care to avoid causing damage or deformities, limiting handling to just the fingertips may not provide adequate support or control. Plaster casts can be fragile when wet, and improper handling techniques may lead to misshaping or weakening of the cast structure. Additionally, relying solely on the fingertips for handling may increase the risk of inadvertently applying uneven pressure or causing accidental damage to the cast material. Therefore, while the intention behind this option is to promote gentle handling, it may not provide sufficient support or control to ensure the integrity of the wet cast.

Choice D rationale:

Monitoring the capillary refill time in the toes on both feet, as indicated in option D, is the most appropriate action for the nurse to take in this scenario. Capillary refill time is a valuable indicator of peripheral circulation and tissue perfusion. By assessing the capillary refill time in the toes, the nurse can evaluate the adequacy of blood flow to the extremities and detect any potential impairment caused by the plaster hip spica cast. Prolonged capillary refill time may suggest compromised circulation, which can lead to serious complications such as ischemia or tissue necrosis if left unaddressed. Therefore, regular monitoring of capillary refill time is essential for early detection of circulation problems and timely intervention to ensure patient safety and optimal outcomes.

In conclusion, while each option may seem plausible at first glance, careful consideration of the potential implications reveals that monitoring capillary refill time in the toes on both feet is the most appropriate action for the nurse to take when caring for a patient with a wet plaster hip spica cast. This proactive approach prioritizes patient safety by ensuring adequate circulation and minimizing the risk of complications associated with impaired blood flow. By adhering to evidence-based practice guidelines and maintaining vigilance in monitoring patient status, healthcare professionals can optimize outcomes and promote the effective healing and management of patients with plaster casts.

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Correct Answer is C

Explanation

Choice A rationale:

Fever and hypertension are not typical findings in moderate dehydration. Dehydration often leads to hypotension rather than hypertension, and fever is not a direct consequence of dehydration.

Choice B rationale:

Increased specific gravity can be a sign of dehydration, but it is not as specific or sensitive as tachypnea (rapid breathing) and tachycardia (elevated heart rate), which occur due to the body's compensatory mechanisms in response to dehydration.

Choice C rationale:

Tachypnea and tachycardia are key indicators of moderate dehydration in infants. The body tries to maintain perfusion by increasing the heart rate and respiratory rate. These signs are more reliable indicators of dehydration than specific gravity or fever.

Choice D rationale:

Bulging posterior fontanel is not a typical finding in dehydration. A sunken fontanel might be more indicative of dehydration, as fluid shifts from the intracellular to the extracellular space.

A. Failing to regularly wash their hands after eating. B. Failing to adequately wipe themselves after toileting. C. Sharing their clothing with friends. D. Engaging in frequent hand-to-mouth activity.

Correct Answer is B

Explanation

Choice A rationale:

Failing to regularly wash their hands after eating may contribute to the transmission of various infections, but it's not specifically related to pinworms.

Choice B rationale:

Failing to adequately wipe themselves after toileting can lead to the transfer of pinworm eggs from the anal area to the fingers and under the nails. This behavior increases the risk of ingesting the eggs through hand-to-mouth contact, which can perpetuate the pinworm infection cycle.

Choice C rationale:

Sharing clothing with friends might facilitate the transmission of certain infections like lice or fungal infections, but it's not a common mode of transmission for pinworms.

Choice D rationale:

Engaging in frequent hand-to-mouth activity might increase the risk of ingesting pinworm eggs, but the eggs are more likely to be present on the hands due to inadequate wiping after toileting.

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A patient is placed in a plaster hip spica cast and is returned to the assigned room. The cast is still slightly wet. Which action by the nurse would be appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing an infant with moderate dehydration, a nurse would expect which assessment findings?

Correct Answer is C

Explanation

A 6-year-old child is brought to the clinic because the mother has noticed the child scratching the anal area frequently. The nurse suspects the child has pinworms. Which childhood behavior enhances the transmission of pinworms?

Correct Answer is B

Explanation

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