The nurse is caring for a child who has had a unilateral long-leg cast applied for the correction of club foot.
What is the most important action for the nurse to perform?

Monitor the capillary refill of the toes.

Compare the temperature of both legs.

Observe for spontaneous movement.

Check the femoral pulses.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Monitoring the capillary refill of the toes is crucial when a child has a long-leg cast applied. This is because it helps assess the adequacy of circulation to the foot, which can be compromised by the cast. If the capillary refill is delayed (more than 2 seconds), it could indicate poor blood flow to the area, which could lead to serious complications such as tissue necrosis.
Choice B rationale
Comparing the temperature of both legs can provide information about circulation and inflammation. However, it is not the most important action in this case. While a significant difference in temperature could indicate a problem, it is not as direct an indicator of circulatory status as capillary refill.
Choice C rationale
Observing for spontaneous movement can provide information about nerve function. If the child is not moving the toes, it could indicate nerve damage. However, lack of movement could also be due to discomfort from the cast and is not as direct an indicator of circulatory status as capillary refill.
Choice D rationale
Checking the femoral pulses can provide information about circulation to the leg. However, the femoral pulse is proximal to the cast and may not accurately reflect circulation to the foot. Therefore, it is not the most important action in this case.

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Correct Answer is C

Explanation

Choice A rationale

Keeping the skin incision moist by periodically wetting the dressing is not the recommended care for a myelomeningocele surgical repair. The dressing needs to be kept dry to prevent infection and promote healing.

Choice B rationale

Removing the tape rapidly from the edges of the dressing during a change is not advised. This could potentially damage the skin and disrupt the healing process.

Choice C rationale

An intact dressing protects the incision from fecal contamination, which is crucial in preventing infection. This statement indicates an understanding of the procedure.

Choice D rationale

While it’s important to keep the dressing dry to ensure easy removal of sutures, it’s not the primary concern. The main goal is to protect the incision from contamination.

A. Variance in blood pressure across extremities. B. Hypotension. C. Tachycardia. D. Pulse oximetry reading within defined limits.

Correct Answer is C

Explanation

Choice A rationale

Variance in blood pressure across extremities is not typically associated with ventricular septal defects (VSDs). VSDs are characterized by a hole in the heart that allows oxygen-rich blood to move back into the lungs instead of being pumped to the rest of the body.

Choice B rationale

Hypotension is not a common symptom of VSDs. Instead, these defects can cause increased blood pressure in the lungs due to the abnormal flow of blood.

Choice C rationale

Tachycardia, or a rapid heart rate, is a common symptom of VSDs, especially in cases where the defect is medium or large. This is because the heart needs to work harder to pump blood, leading to an increased heart rate.

Choice D rationale

While pulse oximetry readings within defined limits could be seen in small VSDs, in larger defects or those causing heart failure, oxygen saturation levels might be lower due to the abnormal circulation of blood.

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The nurse is caring for a child who has had a unilateral long-leg cast applied for the correction of club foot. What is the most important action for the nurse to perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is instructing the parents of a child who underwent a surgical repair of a myelomeningocele on how to change an occlusive dressing on the child’s back. Which parental statement indicates understanding of the procedure?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

The nurse is caring for a toddler with a large, unrepaired ventricular septal defect and heart failure. What assessment finding should the nurse anticipate?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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The nurse is caring for a child who has had a unilateral long-leg cast applied for the correction of club foot.
What is the most important action for the nurse to perform?