A nurse is assessing a child who has multiple closed fractures of the lower extremities due to a motor vehicle crash. The nurse should monitor the child for which of the following complications during the first 24 hr after the injury occurred?
Renal calculi
Osteomyelitis
Compartment syndrome
Volkmann ischemic contracture
The Correct Answer is C
A. Renal calculi (kidney stones) are not directly related to fractures of the lower
extremities. They form in the kidneys and can cause pain and other symptoms when they pass into the urinary tract.
B. Osteomyelitis is a bone infection that can occur as a complication of fractures, but it typically develops over a longer period of time than the first 24 hours after the injury.
C. This is the correct answer. Compartment syndrome is a serious complication of fractures that can occur within the first 24 hours after injury. It is characterized by
increased pressure within a muscle compartment, leading to reduced blood flow, nerve compression, and tissue damage.
D. Volkmann ischemic contracture is a complication that can occur if there is prolonged or severe muscle ischemia (lack of blood flow) following a fracture. It is not typically a concern within the first 24 hours after the injury
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This is the correct action. Offering a pacifier coated with an oral sucrose solution before the injections can provide comfort and help alleviate pain associated with the immunizations.
B. Administering immunizations into the deltoid muscle is not recommended for infants.
For young infants, immunizations are typically given in the anterolateral thigh muscle.
C. Using a 20-gauge needle is not recommended for infants, as it is a larger gauge and may cause more discomfort. A smaller gauge needle is typically used for infant
immunizations.
D. Applying an eutectic mixture of local anesthetics (EMLA) cream immediately before the injections is not a standard practice for routine infant immunizations. It may not be necessary for most infants and could increase the overall time and complexity of the procedure.
Correct Answer is D
Explanation
A. Negative doll's eye reflex (also known as oculocephalic reflex) is a normal finding in infants. It is a reflexive movement of the eyes in the opposite direction of the head
movement.
B. A sunken anterior fontanel can indicate dehydration, which is a concern. However, in a 2-month-old with heart failure, a high heart rate (tachycardia) may indicate worsening of the heart failure and needs to be addressed promptly.
C. A potassium level of 5.1 mEq/L is within the normal range for infants. While electrolyte balance is important, it is not the priority in this situation.
D. This is the correct answer. A heart rate of 162/min in a 2-month-old infant with heart failure is elevated and requires immediate attention. It may indicate worsening heart
failure or an adverse reaction to the medication (furosemide) being administered. The nurse should assess the infant's condition, notify the healthcare provider, and intervene as necessary.
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