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

Answer and Explanation

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.

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Correct Answer is B

Explanation

B. Leaning forward with the chin thrust out, often described as the "sniffing position," is a classic sign of airway obstruction, particularly in cases of epiglottitis. This positioning helps to maximize airway patency by opening the airway and reducing the risk of further obstruction.

A. Leaning forward with the chin thrust out is not typically associated with extreme fatigue. Instead, it is a specific positioning often seen in individuals with epiglottitis to help alleviate airway obstruction and facilitate breathing.

C. Leaning forward with the chin thrust out is not indicative of dehydration. Dehydration may present with other signs and symptoms such as dry mucous membranes, decreased urine output, sunken fontanelle (in infants), and poor skin turgor.

D. Pain may be present in a child with epiglottitis but leaning forward with the chin thrust out is not primarily indicative of pain. This positioning is primarily a compensatory mechanism to alleviate airway obstruction rather than a response to pain.

A. Cool extremities and decreased urine output B. Bradycardia and hypotension C. Increased appetite and excessive weight gain D. Poor feeding and weight gain E. Tachypnea and respiratory distress

Correct Answer is ["A","D","E"]

Explanation

A. Decreased cardiac output in heart failure can lead to poor perfusion of the extremities, resulting in cool skin and decreased urine output due to reduced renal perfusion and impaired kidney function.

D. Poor feeding is often observed due to increased respiratory effort, tachypnea, and fatigue associated with heart failure. Additionally, infants may exhibit failure to thrive or inadequate weight gain despite increased caloric intake due to metabolic demands and inefficient utilization of nutrients.

E. Tachypnea and respiratory distress occur due to pulmonary congestion and increased respiratory effort in response to heart failure. Infants may exhibit signs such as nasal flaring, grunting, retractions, and cyanosis.

B. Bradycardia and hypotension are not typical manifestations of heart failure in infants. Instead, infants with heart failure often present with tachycardia (rapid heart rate) as a compensatory mechanism to maintain cardiac output. Hypotension may occur in severe cases but is not a common finding.

C. Increased appetite and excessive weight gain are not typical manifestations of heart failure in infants. Infants with heart failure often experience poor feeding and failure to thrive due to inadequate cardiac output and oxygen delivery to meet metabolic demands.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse employed in an emergency department is instructed to monitor a child diagnosed with epiglottitis. The nurse notes that the child is leaning forward with the chin thrust out. The nurse interprets this observation as indicating which finding?

Correct Answer is B

Explanation

Which of the following are common manifestations of heart failure in infants? (SELECT ALL THAT APPLY)

Correct Answer is ["A","D","E"]

Explanation

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