A nurse is developing a plan of care for a child who is in skeletal traction following a femur fracture. Which of the following actions should the nurse include in the plan?

Lift the traction weights when repositioning the child in bed.

Have the child rate their level of pain ever-8 hr.

Monitor the neurovascular status of the child's lower extremities every 12 hr.

Educate the child's guardians about pin site care prior to discharge.

Answer and Explanation

The Correct Answer is D

A. Lift the traction weights when repositioning the child in bed.

This action should not be included in the plan of care because lifting the traction weights can interfere with the traction's effectiveness and potentially cause harm or injury to the child. The weights are specifically calibrated to provide the necessary tension for the traction to stabilize the fracture site.

B. Have the child rate their level of pain every 8 hours.

While pain assessment is an essential component of nursing care, the frequency of every 8 hours may not be sufficient, especially for a child in skeletal traction. Pain management should be more frequent and individualized based on the child's needs, which may vary throughout the day.

C. Monitor the neurovascular status of the child's lower extremities every 12 hours.

Neurovascular assessment is crucial for patients in traction to detect any signs of compromised circulation or nerve function. However, every 12 hours may not be frequent enough to promptly identify changes in neurovascular status. More frequent assessments, such as every 1-2 hours initially and then gradually decreasing based on stability, are typically recommended.

D. Educate the child's guardians about pin site care prior to discharge.

This is the correct answer. Educating the child's guardians about pin site care is essential to prevent infection and other complications associated with skeletal traction. Proper care of the pin sites reduces the risk of infection, which can lead to serious complications such as osteomyelitis. Providing education prior to discharge ensures that the guardians are equipped with the necessary knowledge and skills to care for the child at home effectively.

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Correct Answer is D

Explanation

A. "I can expect my eyelids to be bruised after this procedure": Bruising of the eyelids is not a common expectation following cataract removal surgery. While mild redness or irritation may occur, significant bruising is not typical.
B. "I will see dark spots in my vision after this procedure": Seeing dark spots in vision after cataract removal surgery is not expected. The purpose of cataract surgery is to improve vision by removing the cloudy lens and replacing it with a clear artificial lens. Dark spots in vision may indicate complications such as retinal detachment, which should be promptly reported to the healthcare provider.
C. "I will receive general anesthesia for this procedure": Cataract removal surgery typically does not require general anesthesia. Instead, it is commonly performed under local anesthesia with sedation. General anesthesia is reserved for more complex or high-risk procedures. Therefore, this statement indicates a misunderstanding of the anesthesia type for cataract surgery.
D. "I know the provider will replace the lens in my eyes during this procedure": This statement indicates an accurate understanding of the cataract removal procedure. During cataract surgery, the cloudy natural lens of the eye is removed and replaced with an artificial intraocular lens (IOL) to restore vision. This is the primary goal of the surgery, and the statement reflects the client's understanding of the procedure.

A. Wire cutters B. Montgomery straps C. Tracheostomy tray D. Padded clamp

Correct Answer is D

Explanation

A. Wire cutters:
Wire cutters are typically not necessary for postoperative care following a thoracotomy with chest tube placement. They are more commonly used in situations such as removing orthopedic hardware or cutting wires in emergency situations. Therefore, wire cutters are not essential equipment for this particular procedure.

B. Montgomery straps:
Montgomery straps are adhesive strips used to secure dressings or bandages without the need for tape. While they can be useful in some postoperative situations, they are not specifically required for a thoracotomy with chest tube placement.

C. Tracheostomy tray:

A tracheostomy tray contains equipment necessary for performing tracheostomy care, such as sterile gloves, tracheostomy tubes, and suctioning equipment. It is not directly related to thoracotomy or chest tube care post op.

D. Padded clamp:
A padded clamp, or chest tube holder, is a device used to secure chest tubes in place and prevent them from being accidentally dislodged. It is an essential piece of equipment for postoperative care following a thoracotomy with chest tube placement, as it helps maintain the integrity of the chest tubes and prevents complications such as air leaks or pneumothorax.

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A nurse is developing a plan of care for a child who is in skeletal traction following a femur fracture. Which of the following actions should the nurse include in the plan?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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