Page 1146 - Saunders Comprehensive Review For NCLEX-RN

Rationale: When a child is in traction, the nurse would check the PHCP’s
prescription to verify the prescribed amount of traction weight. The nurse would
maintain the correct amount of weight as prescribed, ensure that the weights hang
freely, check the ropes for fraying and ensure that they are on the pulleys
appropriately, monitor the neurovascular status of the involved extremity, and
monitor for signs and symptoms of complications of immobilization. The nurse
would provide therapeutic and diversional play activities for the child.
Test-Taking Strategy: Focus on the subject, care of the child in traction. Eliminate
option 3 first because of the word restrict. Next recall the general principles related to
traction, recalling that weights should hang freely and ropes should remain in the
pulleys.
Level of Cognitive Ability: Creating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Planning
Content Area: Pediatrics: Musculoskeletal
Health Problem: Pediatric-Specific: Fractures
Priority Concepts: Mobility; Safety
Reference: Hockenberry, Wilson, Rodgers (2017), p. 957.

395. Answer: 2

Rationale: Teaching about cast care is essential to prevent complications from the
cast. The parents need to be instructed not to use lotion or powders on the skin
around the cast edges or inside the cast. Lotions or powders can become sticky or
caked and cause skin irritation. Options 1, 3, and 4 are appropriate statements and
indicate the parents understand cast care.
Test-Taking Strategy: Note the strategic words, need for further instruction. These
words indicate a negative event query and ask you to select an option that is an
incorrect statement. Remember that lotions or powders can become sticky or caked
and cause skin irritation.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Pediatrics: Musculoskeletal
Health Problem: Pediatric-Specific: Fractures
Priority Concepts: Client Education; Skin Integrity
Reference: McKinney et al. (2018), p. 1216.

396. Answer: 3

Rationale: Juvenile idiopathic arthritis is an autoimmune inflammatory disease
affecting the joints and other tissues, such as articular cartilage. During painful
episodes of juvenile idiopathic arthritis, hot or cold packs and splinting and
positioning the affected joint in a neutral position help reduce the pain. Although
resting the extremity is appropriate, beginning simple isometric or tensing exercises
as soon as the child is able is important. These exercises do not involve joint
movement.

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