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. 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.

A. "This test will tell me if my baby has a genetic problem." B. "I will get oxytocin during this test." C. "During this test. I must not eat or drink anything." D. "During this test. I will push a button if my baby moves."

Correct Answer is D

Explanation

D. "During this test, I will push a button if my baby moves."

Rationale:
A. "This test will tell me if my baby has a genetic problem." - Nonstress testing (NST) is used to evaluate fetal well-being by assessing fetal heart rate accelerations in response to fetal movement. It does not diagnose genetic problems.
B. "I will get oxytocin during this test." - Oxytocin is not typically administered during nonstress testing. NST is a non-invasive procedure that involves placing a fetal heart rate monitor on the mother's abdomen to monitor the baby's heart rate.
C. "During this test, I must not eat or drink anything." - While it's generally recommended to have a snack or meal before the test to encourage fetal movement, fasting is not required for NST unless otherwise instructed by the healthcare provider.
D. "During this test, I will push a button if my baby moves." - This statement demonstrates an understanding of how NST works. The client is instructed to push a button whenever they feel fetal movement, allowing the healthcare provider to correlate fetal movement with changes in the fetal heart rate pattern.

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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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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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