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 A
Explanation
A. Frequent swallowing is a common finding after a tonsillectomy due to postoperative throat discomfort and the sensation of having a foreign object in the throat (such as blood clots or mucus).
B. Reports of thirst may indicate dehydration, which can occur after surgery, especially if the child is not drinking enough fluids due to pain or discomfort. While dehydration can be a concern after a tonsillectomy, it is not a specific sign of hemorrhage.
C. Pain is common after a tonsillectomy and can be expected in the postoperative period. While increased pain may be present if hemorrhage occurs, it is not a specific sign of hemorrhage on its own.
D.Mouth breathing does not directly indicate bleeding and is more related to discomfort or difficulty breathing through the nose, especially if the child is experiencing throat pain. It is not a typical sign of hemorrhage.
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.
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