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?
The skin incision should be kept moist by periodically wetting the dressing.
When changing the dressing, the tape should be removed rapidly from the edges.
The incision should be protected from fecal contamination by an intact dressing.
To ensure easy removal of the sutures, the dressing should be kept dry.
To ensure easy removal of the sutures, the dressing should be kept dry.
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The child’s symptoms of agitation, fever, and back pain, along with a history of asthma and recurrent urinary tract infections (UTIs), suggest that she may be experiencing another UTI1.
UTIs can cause fever and back pain, and the fever can lead to agitation in young children. Administering the prescribed antipyretic would help to reduce the child’s fever and alleviate some of her discomfort.
Choice B rationale
Obstructive uropathy is a condition where the flow of urine is blocked, which can cause pain and kidney damage. While this condition could potentially cause back pain, the child’s other symptoms such as fever and agitation are more indicative of an infection like a UTI1.
Choice C rationale
Albumin is a protein made by the liver that helps keep fluid in the bloodstream so it doesn’t leak into other tissues. It is not a condition but a substance in the body, and therefore would not be the correct answer to the question.
Choice D rationale
V320 is not a known medical condition or term, and therefore would not be the correct answer to the question.
Correct Answer is C
Explanation
Choice A rationale
Purulent secretions are not typically associated with epiglottitis. Epiglottitis is an inflammation and swelling of the epiglottis and does not usually produce purulent secretions.
Choice B rationale
While a child with epiglottitis may appear anxious due to difficulty breathing, apprehension is not a specific symptom of epiglottitis.
Choice C rationale
A thick, muffled voice is a common symptom of epiglottitis. The inflammation and swelling of the epiglottis can affect the child’s voice, making it sound thick and muffled.
Choice D rationale
Wheezing is not typically a symptom of epiglottitis. While breathing difficulties are common in epiglottitis, they are usually due to the swelling of the epiglottis rather than constriction of the airways, which causes wheezing.
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