A nurse is caring for an adolescent following the application of a plaster cast for a fractured right tibia.
Which of the following actions should the nurse take?
Discourage the client from ambulating.
Keep the client's leg in a dependent position.
Use a hair dryer on a hot setting to dry the cast.
Perform a neurovascular check of the lower extremities.
The Correct Answer is D
Choice A rationale
Discouraging the client from ambulating is not necessary. In fact, early ambulation is often encouraged to promote circulation and prevent complications, depending on the fracture
type and treatment plan.
Choice B rationale
Keeping the client's leg in a dependent position is not recommended as it can increase swelling and pain. Elevating the leg is typically advised to reduce swelling.
Choice C rationale
Using a hair dryer on a hot setting to dry the cast is unsafe as it can cause burns and damage the cast. It's better to allow the cast to dry naturally and follow the healthcare provider's
instructions.
Choice D rationale
Performing a neurovascular check of the lower extremities is crucial to assess circulation, sensation, and movement. This helps in identifying any complications such as impaired
blood flow or nerve damage.
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Correct Answer is C
Explanation
Choice A rationale
Allowing an additional 30 minutes of play before bedtime can lead to overstimulation and delay the child's ability to settle down for sleep. Consistent bedtime routines are crucial for
establishing healthy sleep patterns in children.
Choice B rationale
Letting the child sleep in the parent's bed can create dependency and difficulty in establishing the child's own sleep routine and space. This practice can disrupt both the parent's and
child's sleep in the long term.
Choice C rationale
Keeping a night light on provides a sense of security and comfort for a child who may be afraid of the dark. This helps the child feel safe and can ease the transition to bedtime.
Choice D rationale
Staying with the child until they fall asleep, especially if crying, can reinforce the behavior and make it harder for the child to develop self-soothing skills. It can lead to increased
dependency on the parent's presence to fall asleep.
Correct Answer is A
Explanation
Choice A rationale
Applying a sterile, moist dressing on the sac helps prevent infection and keeps the tissue moist, promoting healing.
Choice B rationale
Monitoring the infant's temperature rectally can increase the risk of infection and is not recommended.
Choice C rationale
Encouraging the guardian to cuddle with the infant is important for bonding but doesn't directly address the care of myelomeningocele.
Choice D rationale
Maintaining the infant in a supine position can put pressure on the sac, increasing the risk of rupture and infection.