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 A
Explanation
Choice A rationale:
Swelling around the eyelids and mouth could indicate an allergic reaction, which can be severe in some cases. Anaphylaxis is a life-threatening reaction that can occur after immunizations. The nurse's priority is to assess and address any signs of an allergic reaction promptly. Swelling of the face, particularly around the eyes and mouth, is a red flag for potential anaphylaxis, and immediate intervention is necessary to prevent further complications.
Choice B rationale:
A temperature of 100.7 degrees Fahrenheit is considered a mild fever. While it's important to monitor for fever after immunizations, a mild fever alone may not be the nurse's top priority, especially if the child is otherwise stable. Fever can be a common post-immunization response and is often self-limiting.
Choice C rationale:
While monitoring the child's intake is important, only eating 2 ounces during the last feeding is not a priority concern compared to potential allergic reactions or fever. A temporary decrease in appetite following immunizations can be expected and might resolve on its own.
Choice D rationale:
Crying when the injection site is touched is a common response to discomfort from the shot. While it's essential to provide comfort and support to the child, this finding is not indicative of a severe reaction. It's not the nurse's priority compared to potential signs of an allergic reaction or a more significant fever.
Correct Answer is A
Explanation
Choice A rationale:
Hypertension is a common manifestation of acute glomerulonephritis. The inflammation of the glomeruli in the kidneys can lead to impaired filtration, causing fluid retention and an increase in blood pressure. Monitoring the child's blood pressure is crucial to assess the severity of the condition and guide appropriate interventions.
Choice B rationale:
Dehydration is not a typical manifestation of acute glomerulonephritis. In fact, this condition often leads to fluid retention due to impaired kidney function. The child might experience edema and hypertension rather than dehydration.
Choice C rationale:
Muehrcke lines on the nails are not associated with acute glomerulonephritis. Muehrcke lines are white lines that appear horizontally across the nails and are typically indicative of hypoalbuminemia, which is not a primary feature of glomerulonephritis.
Choice D rationale:
Hypokalemia, or low potassium levels, is not a characteristic manifestation of acute glomerulonephritis. This condition primarily affects the kidneys' ability to filter waste and excess fluid, leading to fluid retention, electrolyte imbalances, and hypertension.
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