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. 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.

A. Nausea and vomiting B. Improved appetite C. Increased urine output D. Decreased heart rate

Correct Answer is A

Explanation

A. Nausea and vomiting are potential adverse effects of digoxin in children. Digoxin is a medication commonly used to treat heart conditions, but it can cause gastrointestinal disturbances as a side effect. Nausea and vomiting may occur, especially if the child is receiving too high a dose of digoxin or if they are particularly sensitive to the medication.

B. Improved appetite would not typically indicate an adverse effect of digoxin. In fact, digoxin is not known to have a direct effect on appetite. If a child experienced an increase in appetite while taking digoxin, it would likely be unrelated to the medication or could be due to other factors.

C. Increased urine output would not typically indicate an adverse effect of digoxin. Digoxin is not a diuretic medication, so it would not directly cause increased urine output.

D. Digoxin is not commonly associated with bradycardia in children.

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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

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Correct Answer is A

Explanation

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