A nurse is caring for a child who has Legg-Calve-Perthes disease and is in Buck extension traction.
Which of the following actions should the nurse take?
Reposition the child every 2 hr.
Remove the traction boot during baths.
Reduce fluid intake.
Apply antibiotic ointment to pin sites daily.
The Correct Answer is A
The correct answer is choice a. Reposition the child every 2 hr.
Choice A rationale:
Repositioning the child every 2 hours is essential to prevent complications such as pressure ulcers and to promote comfort and circulation.
Choice B rationale:
Removing the traction boot during baths is not recommended as it can disrupt the traction setup and potentially worsen the condition.
Choice C rationale:
Reducing fluid intake is not necessary for managing Legg-Calve-Perthes disease and could lead to dehydration.
Choice D rationale:
Applying antibiotic ointment to pin sites daily is not applicable in this scenario as Buck extension traction typically does not involve pin sites.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Isotretinoin has been associated with depression and other psychiatric side effects.
The client should report any changes in mood or behavior, including feelings of isolation, to the provider immediately.
Choice B is not an answer because while frequent nosebleeds can be a side
effect of isotretinoin, it is not the priority to report to the provider.
Choice C is not an answer because while back pain can be a side effect of isotretinoin, it is not the priority to report to the provider.
Choice D is not an answer because while itching of the skin can be a side effect of isotretinoin, it is not the priority to report to the provider.
Correct Answer is A
Explanation
A.Infants with spina bifida, including those with myelomeningocele, have an increased risk of rectal anomalies, so avoiding rectal temperatures is essential. The correct and safe method of temperature measurement for these infants is typically axillary.
B. Placing the infant in a side-lying positionis not recommended for a child with myelomeningocele. The preferred position isprone to avoid pressure on the sac and reduce the risk of rupture and infection.
C.Maintains a dry dressing over the sac: While the sac should be kept covered, it is typically kept moist with sterile saline-soaked gauze to prevent it from drying out and to minimize the risk of infection.
D.Performs range of motion on the infant's hips: Range of motion exercises might be indicated later on, but initially, the focus is on protecting the sac and preventing complications.
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