An infant is admitted to the unit with a diagnosis of bladder exstrophy. What should the nurse prioritize when caring for a client with this condition?
Increasing fluid intake
Inserting an indwelling catheter
Maintaining prone positioning
Preventing skin breakdown
The Correct Answer is D
A. Increasing fluid intake is important for overall health but is not the primary concern in the initial management of bladder exstrophy.
B. Inserting a catheter may be necessary but is not the first priority in managing bladder exstrophy.
C. Prone positioning is generally not recommended for infants with bladder exstrophy; supine positioning may be preferable to prevent pressure on the exposed bladder.
D. Preventing skin breakdown is critical due to the constant exposure of the bladder and surrounding skin to urine, leading to a high risk of irritation and infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While reviewing the CBC is important, it is not the priority.
B. Assessing joint pain is necessary for managing symptoms, but it is not the most critical initial action.
C. Evaluating the erythematous rash is part of the assessment, but it does not take precedence.
D. Auscultating the heart is the priority because acute rheumatic fever can lead to carditis, which can cause significant and potentially life-threatening heart complications. Early detection of abnormal heart sounds is crucial.
Correct Answer is B
Explanation
A. The child’s reluctance to change clothes in front of others might suggest body image issues, but it doesn’t directly indicate spinal curvature.
B. Difficulty finding pants that fit evenly over the hips could indicate a scoliosis-related curvature, where one hip may be higher than the other.
C. Back pain could be related to various conditions, including scoliosis, but by itself, it’s not definitive for spinal curvature.
D. Daily use of ibuprofen for hip pain may indicate musculoskeletal issues but doesn’t directly relate to spinal curvature or scoliosis.
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