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. This option is the most appropriate choice for an infant with respiratory syncytial virus (RSV). RSV is highly contagious and primarily spreads through respiratory secretions. Placing the infant in a private room helps to minimize the risk of transmission to other patients. Contact and droplet precautions should be implemented to further prevent the spread of the virus.
B. This choice is not ideal because both RSV and croup are respiratory infections that can spread easily among infants. Placing an infant with RSV in a semi-private room with another infant increases the risk of transmission of both infections to each other.
C. While isolating the infant in a private room is appropriate for preventing the spread of RSV, the term "protective isolation" typically refers to a type of isolation used for patients who have compromised immune systems.
D. Placing the infant with RSV in a semi-private room with a toddler who has pneumonia is not recommended. Both RSV and pneumonia are respiratory infections that can spread easily among patients, especially infants and young children who are more susceptible to complications.
Correct Answer is D
Explanation
D. Warm compresses or heat therapy are not recommended for the initial management of a sprained ankle, especially within the first 24 hours. Heat can increase blood flow and exacerbate swelling and inflammation, which may worsen pain and delay healing.
A. Applying ice packs in this manner helps reduce inflammation and swelling, which are common after a sprain. Alternating ice application with periods of rest allows for effective cooling without causing tissue damage.
B. Wrapping the ankle in an Ace bandage can provide compression and support, which may help reduce swelling and stabilize the joint during the healing process. However, it's important not to wrap the bandage too tightly, as this can impair circulation.
C. Elevating the leg when sitting helps reduce swelling by promoting venous return and preventing fluid accumulation in the injured area. Keeping the ankle elevated above the level of the heart whenever possible is recommended for optimal swelling reduction.
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