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 D

Explanation

D. If the tympanostomy tubes fall out, the parent should contact the healthcare clinic or the healthcare provider who performed the procedure. They can provide guidance on whether the child needs to be seen for an evaluation and potential replacement of the tubes. Reporting the situation allows for appropriate follow-up and management by the healthcare team.

A. Tympanostomy tubes are small tubes inserted into the eardrums to help drain fluid from the middle ear and prevent recurrent ear infections. While they are designed to stay in place for a certain period, it is possible for them to fall out prematurely.

B. It's important for the parent to seek medical advice if the tubes fall out but it may not always require an immediate visit to the emergency department. However, if the child experiences severe pain, bleeding, or signs of infection after the tubes fall out, seeking urgent medical attention may be warranted.

C. Only a healthcare provider should insert or reinsert tympanostomy tubes. Attempting to reinsert the tubes at home without proper training and equipment could cause injury or damage to the ear.

A. Sweat chloride test B. Stool fat content analysis C. Sputum culture D. Pulmonary function test

Correct Answer is A

Explanation

A. The sweat chloride test is considered the most definitive diagnostic test for cystic fibrosis. In this test, sweat is collected from the skin and analyzed for chloride content. Elevated levels of chloride in the sweat are indicative of cystic fibrosis. This test is highly sensitive and specific for diagnosing the condition.

B. Stool fat content analysis can help assess pancreatic function and malabsorption, which are common manifestations of cystic fibrosis. However, it is not considered the most definitive test for diagnosing cystic fibrosis. Elevated stool fat content can be suggestive of cystic fibrosis but is not specific to the condition.

C. Sputum culture may be performed to identify respiratory pathogens and guide antibiotic therapy in individuals with cystic fibrosis, but it is not the most definitive test for diagnosing the condition. It helps identify infections and monitor lung health but does not confirm the diagnosis of cystic fibrosis.

D. Pulmonary function tests are used to assess lung function and airflow, which can be affected in individuals with cystic fibrosis. While these tests provide valuable information about lung health, they are not the most definitive test for diagnosing cystic fibrosis. They are used for monitoring disease progression and response to treatment rather than confirming the diagnosis.

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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

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Correct Answer is D

Explanation

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Correct Answer is A

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