A child has a right femur fracture caused by a motor vehicle crash and is placed in skin traction temporarily until surgery can be preformed. During assessment, the nurse notes that the dorsalis pedis pulse is absent on the right foot. Which action should the nurse take?
Notify the health care provider (HCP)
Administer an analgesic
Release the skin traction
Apply ice to the extremity
The Correct Answer is A
A. The absence of the dorsalis pedis pulse in the right foot is concerning and could indicate compromised circulation to the extremity. It is essential to notify the healthcare provider promptly so that further assessment and intervention can be initiated to address the circulation issue and prevent potential complications such as ischemia or tissue damage.
B. Administering an analgesic may be necessary to manage the child's pain, especially if they are experiencing discomfort due to the femur fracture. However, addressing the absent dorsalis pedis pulse takes priority as it suggests a potential vascular problem that requires immediate attention.
C. Releasing the skin traction may not be appropriate at this point without further assessment and guidance from the healthcare provider. Skin traction is often used to temporarily stabilize fractures and reduce pain, and releasing it without proper evaluation could potentially exacerbate the injury or compromise the child's comfort and stability.
D. Applying ice to the extremity is not indicated in this situation. Ice application is typically used for acute injuries to reduce swelling and inflammation, but it is not appropriate when there is concern about compromised circulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. The priority during a seizure is to protect the patient from harm, particularly from aspiration if they vomit or have excessive saliva production. Turning the client to a lateral position helps maintain an open airway and prevents aspiration. This action should be taken immediately after lowering the client to the floor to ensure their safety.
A. Providing oxygen is important for a patient experiencing a seizure. However, it's not the first action to take. The priority is to ensure the patient's safety and protect them from injury during the seizure.
B. Administering anticonvulsant medication during an active seizure is not appropriate. Anticonvulsants are typically prescribed as maintenance therapy to prevent seizures or to manage seizure disorders in a controlled manner, not during an acute seizure episode.
D. Monitoring oxygen saturation is important but it's not the first action to take during an active seizure. Ensuring the patient's safety and protecting them from injury take precedence. Oxygen saturation can be assessed once the patient is in a safe position.
Correct Answer is B
Explanation
The nurse should ensure that the rope knots are positioned away from the pulleys to prevent interference with the traction mechanism. Proper alignment of the rope and pulleys ensures smooth traction application and prevents accidental slippage or dislodgment of the traction weights.
A. Buck's traction typically does not involve pin sites. It involves the application of traction to the affected limb using a boot or traction tape. Antibiotic ointment is not typically applied to the skin under Buck's traction unless there are specific wounds or abrasions that require treatment.
C. Ensuring the child's feet are against the footboard is not applicable to Buck's traction, which does not require the feet to be against a footboard.
D. There is typically no need to reduce a child's fluid intake solely because they are in Buck's traction for Legg-Calve-Perthes disease. Adequate hydration is essential for overall health and healing, and fluid restriction is not indicated unless there are specific medical reasons for doing so.
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