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 ["B","D"]
Explanation
Choice A rationale:
Allowing an adolescent driver to answer their phone while driving can lead to distraction, increasing the risk of accidents. Engaging in conversations on the phone diverts the driver's attention from the road, which is unsafe. It's crucial for drivers, especially new ones, to focus solely on driving to prevent accidents.
Choice B rationale:
This choice is correct. Not answering the phone while driving is a responsible behavior that indicates an understanding of the dangers of distracted driving. Parents should encourage their children to focus on the road and avoid distractions like phone calls, promoting safe driving practices.
Choice C rationale:
This statement is incorrect. Adolescents should continue wearing helmets when riding their bikes even after age 13. Wearing helmets helps prevent head injuries in case of accidents. While older adolescents might perceive themselves as less prone to accidents, they are still at risk, and helmets are essential for their safety.
Choice D rationale:
This choice is correct. Wearing appropriate protective clothing, like long pants, while driving an all-terrain vehicle (ATV) is crucial. Long pants can provide some degree of protection against scrapes, scratches, and minor injuries that can occur while operating an ATV. It's a safety measure that shows an understanding of the importance of protective gear.
Correct Answer is C
Explanation
Choice A rationale:
A 2 cm scalp laceration, while a concern, is not the nurse's priority in this scenario. The child's head injury could potentially be serious, but priority should be given to neurological assessments and signs of increased intracranial pressure.
Choice B rationale:
Nasal discharge negative for glucose is not indicative of a major issue in this context. While cerebrospinal fluid (CSF) leaking from the nose after head trauma is a concern, it is not mentioned in this scenario, and this choice does not take precedence over other neurological signs.
Choice C rationale:
This is the correct answer. Asymmetric pupils can be a sign of a serious neurological issue, such as a brain injury or increased intracranial pressure. It requires immediate attention and further evaluation to assess the child's neurological status and determine the extent of the injury.
Choice D rationale:
A negative Babinski reflex is a normal finding in this context and does not require immediate priority attention. The Babinski reflex is typically present in infants and disappears as the child grows older. Its absence is expected in older children and adults.
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