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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Placental abruption: Placental abruption is characterized by the premature separation of the placenta from the uterine wall before delivery of the fetus. Sudden, severe abdominal pain, moderate to severe vaginal bleeding, persistent uterine contractions, and uterine rigidity are classic signs and symptoms of placental abruption. Hypotension may occur due to hemorrhage, leading to decreased perfusion to vital organs.
B. Uterine rupture: Uterine rupture involves a tear in the uterine wall, which can lead to severe abdominal pain, vaginal bleeding, and signs of shock. However, uterine rupture typically occurs during labor or delivery, particularly in women with a history of uterine surgery or trauma.
C. Placenta previa: Placenta previa is characterized by the implantation of the placenta over or near the internal cervical os. It can cause painless vaginal bleeding in the third trimester, particularly after 20 weeks of gestation. However, it is not typically associated with severe abdominal pain or uterine rigidity.
D. Amniotic fluid embolus: An amniotic fluid embolus occurs when amniotic fluid, fetal cells, hair, or other debris enter the maternal circulation, leading to a potentially life-threatening reaction. Symptoms may include sudden dyspnea, hypotension, cardiovascular collapse, and disseminated intravascular coagulation (DIC). While it can cause severe complications, the symptoms described in the scenario are more consistent with placental abruption.

A. A client who has a right peripherally inserted central catheter B. A client who had a right hemisphere stroke C. A client who had blood drawn from the right antecubital area 1 hr ago D. A client who had dialysis and is using an arteriovenous shunt in the left lower forearm

Correct Answer is A

Explanation

A. A client who has a right peripherally inserted central catheter (PICC):
When a client has a right-sided PICC, it's essential to measure blood pressure in the left arm. This is because the PICC line can interfere with accurate blood pressure readings on the right side due to the placement of the cuff and potential obstruction of blood flow. Measuring blood pressure in the left arm provides a more accurate assessment of systemic blood pressure.

B. A client who had a right hemisphere stroke:
While clients with a right hemisphere stroke may have various neurological deficits, there is no specific indication to measure blood pressure in the left arm based solely on this condition.

C. A client who had blood drawn from the right antecubital area 1 hr ago:
Blood drawn from the antecubital area typically does not affect blood pressure measurements in the same arm. Therefore, there is no need to measure blood pressure in the opposite arm in this situation.

D. A client who had dialysis and is using an arteriovenous shunt in the left lower forearm:
While clients with arteriovenous shunts may have altered blood flow dynamics, the use of a shunt in the left lower forearm does not necessarily require blood pressure measurements to be taken in the opposite arm. Blood pressure measurement should be performed on the side without the shunt unless contraindicated for other reasons.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is observing an assistive personnel (AP) measure blood pressures from the right arms of a group of clients. The nurse should instruct the AP to measure the blood pressure in the left arm of which of the following clients?

Correct Answer is A

Explanation

A nurse is planning postoperative care for a client who is scheduled for a thoracotomy with chest tube placement. Which of the following pieces of equipment should the nurse plan to have at the client's bedside?

A nurse is documenting admission data for a client on an acute care facility. Which of the following actions should the nurse take?

A nurse is caring for a client who has a peritoneal catheter that requires a dressing change. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A nurse in a provider's office is talking with an older adult client who tells the nurse that they fear they are "aging badly" and feel "so useless." Which of the following assessment questions is the nurse's priority?

A nurse is caring for a client who is taking disulfiram for alcohol use disorder and reports ingestion of alcohol. For which of the following adverse effects should the nurse monitor?

A nurse is monitoring a client who is receiving a transfusion of packed RBCs. The client reports chills, headache, low-back pain, and a feeling of "tightness" in their chest. The nurse should identify that the client has developed which of the following types of transfusion reactions?

A nurse is teaching a client who is postpartum about caring for their newborn's umbilical cord. Which of the following instructions should the nurse include?

A nurse is caring for a client who is 2 days postpartum. Which of the following findings should the nurse report to the provider?