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. Salicylates, such as aspirin, should be avoided in children and adolescents with viral symptoms due to the association with Reye's syndrome. Instead, acetaminophen or other non-steroidal anti-inflammatory drugs (NSAIDs) without salicylates should be used for fever and pain relief.
A. Reye's syndrome typically presents with symptoms such as fever, vomiting, and lethargy. However, there isn't a specific test for Reye's syndrome itself. Diagnosis is often based on clinical symptoms, history of aspirin use, and laboratory findings.
B. Reye's syndrome is associated with the use of aspirin (salicylates) in children and adolescents with viral infections, particularly influenza and chickenpox. Acetaminophen (Tylenol) is recommended instead of aspirin for fever and pain relief in children with viral illnesses.
D. There isn't a specific vaccine for Reye's syndrome. Reye's syndrome is not caused by an infectious agent that can be prevented through vaccination.
Correct Answer is ["A","B","D","E"]
Explanation
A. Observation for increasing intracranial pressure is a critical intervention in the care of a child with infectious meningitis. Meningitis can lead to inflammation of the meninges, which may result in increased pressure within the skull.
B. Isolation precautions may be necessary depending on the causative organism and mode of transmission of the infectious meningitis. Bacterial meningitis, for example, may require droplet precautions to prevent the spread of infection to others.
D. Lumbar puncture (also known as a spinal tap) is a diagnostic procedure often performed to collect cerebrospinal fluid (CSF) for analysis in cases of suspected meningitis. It is an essential intervention in the diagnostic workup of infectious meningitis as it helps identify the causative organism and guide appropriate treatment.
C. Seizure precautions are important for children with infectious meningitis, as meningitis can increase the risk of seizures due to inflammation and irritation of the brain.
C. Bright lights can exacerbate symptoms such as headache and photophobia (sensitivity to light) in patients with meningitis, especially during the acute phase of illness. Therefore, it is not advisable to turn lights on to brighten the room for a child with infectious meningitis.
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