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 B
Explanation
The nurse should suspect candidiasis, also known as oral thrush.
Candidiasis is a fungal infection that can occur in the mouth and is characterized by the presence of a white, milky plaque that does not come off with rubbing.
The child’s use of antibiotics, immunosuppressants, and corticosteroids can increase the risk of developing candidiasis.
Choice A is incorrect because dermatitis is an inflammation of the skin and
would not present as a white plaque in the mouth.
Choice C is incorrect because herpes simplex typically presents as painful blisters or sores in the mouth.
Choice D is incorrect because squamous cell carcinoma typically presents as a firm, painless growth, or ulcer in the mouth.
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.
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