The nurse is teaching the parents of a child with developmental dysplasia of the hip (DDH) regarding the application of the Pavlik harness. Which of the following information should the nurse include in the teaching?

Correct Answer: D

Rationale: The correct information that the nurse should include in the teaching is that clothing should always fit loosely over the harness. This is important to prevent restriction of movement and ensure comfort for the child wearing the Pavlik harness. Tight clothing can cause discomfort, skin irritation, and interfere with the effectiveness of the harness in positioning the hip properly. Parents should be advised to choose clothing that is loose-fitting and does not put pressure on the harness or the child's skin.

Correct Answer: B

Rationale: Aling Iska's hemoglobin level of 11mg/dl and hematocrit level of 32% are both below the normal range for her age group. These low levels indicate anemia, which is a condition characterized by a decrease in the number of red blood cells or hemoglobin in the blood. Anemia can be caused by various factors, such as nutritional deficiencies (iron, vitamin B12, folate), chronic diseases, or bone marrow problems. In this case, given Aling Iska's advanced age of 78 years, it is essential for the nurse to conduct a thorough nutritional assessment to determine if her anemia is related to any deficiencies that can be addressed through dietary changes or supplementation. It is important to identify the underlying cause of anemia to provide appropriate interventions and prevent further complications.

Correct Answer: A

Rationale: Pursed lip breathing is a breathing technique commonly used to help improve breathing efficiency in individuals with respiratory conditions such as chronic obstructive pulmonary disease (COPD). By pursing the lips during exhalation, it creates back pressure that helps to keep the airways open longer. This results in slower and more controlled expiration, allowing the individual to exhale a smaller volume of air while maintaining adequate oxygen exchange. This can reduce the feeling of dyspnea (difficulty breathing) and help improve oxygen saturation levels in the blood.

Correct Answer: B

Rationale: Offering softer food may not address the underlying issue of refusal.

Correct Answer: D

Rationale: An adult with a central venous line should include monitoring for any signs of infection, air embolus, and leakage or puncture in the plan of care. Central venous lines carry a risk of complications such as infection, air embolism, and mechanical issues like leakage or puncture. These complications can be serious and require immediate attention to prevent further harm to the patient. Regular monitoring and assessment for these potential issues are crucial in providing safe care for a patient with a central venous line. Other options (A, B, C) may be important in the overall care but monitoring for complications is the priority.