Free NCLEX-RN Exam Braindumps (page: 93)

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The nurse is teaching a mother care of her child's spica cast. The mother states that he complains of itching under the edge of the cast. One nonpharmacological technique the nurse might suggest would be:

  1. "Blowing air under the cast using a hair dryer on cool setting often relieves itching."
  2. "Slide a ruler under the cast and scratch the area."
  3. "Guide a towel under and through the cast and moveit back and forth to relieve the itch."
  4. "Gently thump on cast to dislodge dried skin that causes the itching."

Answer(s): A

Explanation:

(A) Cool air will often relieve pruritus without damaging the cast or irritating the skin. (B) The nurse should never force anything under the cast, because the cast may become damaged and skin breakdown may occur. (C) Forcing an object under the cast could lead to cast damage and skin breakdown. The object may become lodged under the cast necessitating cast removal. (D) This technique does not dislodge skin cells. It could damage the cast and cause skin breakdown.



The nurse is teaching a mother care of her child's spica cast. The mother states that he complains of itching under the edge of the cast. One nonpharmacological technique the nurse might suggest would be:

  1. "Blowing air under the cast using a hair dryer on cool setting often relieves itching."
  2. "Slide a ruler under the cast and scratch the area."
  3. "Guide a towel under and through the cast and moveit back and forth to relieve the itch."
  4. "Gently thump on cast to dislodge dried skin that causes the itching."

Answer(s): A

Explanation:

(A) Cool air will often relieve pruritus without damaging the cast or irritating the skin. (B) The nurse should never force anything under the cast, because the cast may become damaged and skin breakdown may occur. (C) Forcing an object under the cast could lead to cast damage and skin breakdown. The object may become lodged under the cast necessitating cast removal. (D) This technique does not dislodge skin cells. It could damage the cast and cause skin breakdown.



Nursing interventions designed to decrease the risk of infection in a client with an indwelling catheter include:

  1. Cleanse area around the meatus twice a day
  2. Empty the catheter drainage bag at least daily
  3. Change the catheter tubing and bag every 48 hours
  4. Maintain fluid intake of 1200­1500 mL every day

Answer(s): A

Explanation:

(A) Catheter site care is to be done at least twice daily to prevent pathogen growth at the catheter insertion site. (B) Catheter drainage bags are usually emptied every 8 hours to prevent urine stasis and pathogen growth. (C) Tubing and collection bags are not changed this often, because research studies have not demonstrated the efficacy of this practice. (D) Fluid intake needs to be in the 2000­2500 mL range if possible to help irrigate the bladder and prevent infection.



Nursing interventions designed to decrease the risk of infection in a client with an indwelling catheter include:

  1. Cleanse area around the meatus twice a day
  2. Empty the catheter drainage bag at least daily
  3. Change the catheter tubing and bag every 48 hours
  4. Maintain fluid intake of 1200­1500 mL every day

Answer(s): A

Explanation:

(A) Catheter site care is to be done at least twice daily to prevent pathogen growth at the catheter insertion site. (B) Catheter drainage bags are usually emptied every 8 hours to prevent urine stasis and pathogen growth. (C) Tubing and collection bags are not changed this often, because research studies have not demonstrated the efficacy of this practice. (D) Fluid intake needs to be in the 2000­2500 mL range if possible to help irrigate the bladder and prevent infection.



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