Question 9 is not a select-all question, or at least it wasn't for me. So I did this, to help me learn and to clarify the answers.
If unable to reach Cora’s parents, what guidelines will determine the staff’s ability to provide needed care?
Emergency care may be provided after a reasonable attempt to reach the parents had been made.
Since Cora’s parents are divorced, which parent should the nurse try to contact first?
The parent who has been assigned legal custody of Cora by the court.
How is the presence of crepitus related to this femur fracture determined?
Listen for a grating sound when the affected area is moved.
Which feature identifies Cora’s fracture as an open fracture?
Bone fragments protruding through the skin.
Implementation of which nursing intervention will reduce this risk?
Initiate hourly assessment of Cora’s foot distal to the fracture site.
Which action should the nurse implement?
Administer another dose of morphine immediately.
What volume of medication should the nurse administer?
0.3mL
Which traction is a type of skeletal traction?
90-90 Femoral
Which nursing intervention should be included in the plan of care while Cora is in traction?
Ensure that the amount of weight remains consistent.
Which nursing intervention should be included in the plan of care to prevent this complication?
Cleanse around the pin site with half-strength hydrogen peroxide.
Which change in serum lab values would most likely indicate the onset of osteomyelitis?
Increased erythrocyte sedimentation rate (ESR).
Which nursing action has the highest priority?
Assess the appearance of Cora’s foot.
What additional assessment should the nurse perform?
Toe movement.
In addition to notifying the healthcare provider of this development, what action should the nurse implement?
Obtain equipment needed for cast removal.
Given the available nursing personnel, what staff assignment is best?
Ongoing monitoring of Cora’s foot by the LPN, while the UAP assists the postoperative client with crutches, and the RN determines if the new client has any immediate problems.
Which task should be delegated to the LPN at this time?
Spend time with Cora to distract her from the discomfort.
What snack selection is the best choice for Cora?
Pudding.
What action should the nurse take?
Give Cora a few crackers and stay with her while she eats them.
Which activity is the best choice for Cora?
Pretend beauty parlor.
How should the nurse respond to the situation?
Support the mother’s decision to hold Cora accountable for her own misbehavior.
What is the best response by the nurse?
“It is natural to be upset when your child expresses anger toward you.”
In teaching the mother, what response should the nurse suggest she use with Cora?
“I am sad that you are throwing things at me.”
For which problem should Cora’s parents be instructed to call the healthcare provider?
Warm spots are felt on the cast.
What action should the nurse take?
Acknowledge that the parents have correctly learned how to move the cast while wet.
What technique is most beneficial when preparing a preschooler for a procedure that may be frightening?
Describe what the child will experience shortly before the procedure takes place.
How should the nurse respond?
Instruct this parent that the child’s age and size still require the use of a safety seat.
When an older child is sitting in a booster seat, where is the best place to locate the seat?
Back seat of a car with lap and shoulder belts.
Fun fact - my hospital uses chlorhexidine to clean around pins instead of the H202, because according to evidence-based study and practice, the use of hydrogen peroxide (diluted or not) tends to oxidize (read: RUST) the metal pins. In fact, some evidence suggests hydrogen peroxide may have little or no antimicrobial effect. You should check with your client's HCP and/or hospital protocol to be sure.
More trivia your brain doesn't need!
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