A nurse is caring for a preschooler who is in 90-90 traction. Which of the following is the nurse's priority action?
Administer pain medication.
Check capillary refill.
Cleanse and dress the pin sites.
Reposition the child every 2 hr.
The Correct Answer is B
Choice A rationale:
Administer pain medication. Administering pain medication is important for the preschooler's comfort, but it is not the nurse's priority action in this scenario. The priority is to ensure adequate circulation to the extremities, which can be assessed by checking capillary refill.
Choice B rationale:
Check capillary refill. This is the correct answer because the nurse's priority is to assess the child's circulation and tissue perfusion. In 90-90 traction, there is a risk of impaired circulation to the extremities due to the positioning. Checking capillary refill provides information about the adequacy of blood flow to the capillaries and is crucial for early detection of any circulation problems.
Choice C rationale:
Cleanse and dress the pin sites. While caring for the pin sites is important to prevent infection, it is not the priority action at this moment. Ensuring proper circulation and perfusion takes precedence over pin site care.
Choice D rationale:
Reposition the child every 2 hr. Repositioning the child is important to prevent complications associated with immobility, but it is not the nurse's priority action in this situation. The primary concern is to assess and address any circulation issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Acute otitis media is not a risk factor for physical maltreatment. It's an ear infection and does not directly contribute to the risk of physical abuse. The child's medical history should be assessed for factors that are more closely related to abuse.
Choice B rationale:
Myopia, or nearsightedness, is also not a risk factor for physical maltreatment. Myopia is a visual impairment and is not related to the risk of abuse. The nurse should focus on identifying factors that might indicate an increased likelihood of abuse.
Choice C rationale:
Prematurity can be a risk factor for various health issues in a child, but it is not directly linked to physical maltreatment. While preterm infants might have unique medical needs, being born prematurely does not inherently increase the risk of physical abuse.
Choice D rationale:
Correct Answer. Being adopted can be considered a potential risk factor for physical maltreatment. Children who are adopted might face certain challenges related to attachment, identity, and adjustment. It's important for healthcare providers to be vigilant and assess the child's situation comprehensively to ensure their safety and well-being.
Correct Answer is B
Explanation
The correct answer is choiceb. Perceives death as a punishment.
Choice A rationale:
Preschool-aged children generally do not understand that death is permanent.They often view death as temporary or reversible, similar to what they see in cartoons.
Choice B rationale:
Preschoolers may perceive death as a punishment for something they did or thought.This age group often feels guilt and shame, believing their actions or thoughts caused the illness or death.
Choice C rationale:
Worrying about physical body changes is more typical in older children who have a better understanding of the physical aspects of illness and death.
Choice D rationale:
Feelings of isolation are more common in older children and adolescents who are more aware of social dynamics and the implications of their illness.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today