A nurse is caring for a toddler who has a fractured right femur and is in Bryant traction. When determining that the traction is appropriately assembled, the nurse should observe which of the following?
Weights are attached to a pin that is inserted into the femur.
Skin straps maintain the leg in an extended position.
A padded sling is under the knee of the affected leg.
The buttocks is elevated slightly off of the bed.
The Correct Answer is D
Choice A reason: This is not a correct description of Bryant traction. This type of traction does not involve pins or wires inserted into the bone. It is a skin traction that uses adhesive straps or bandages attached to the skin of the lower legs.
Choice B reason: This is not a correct description of Bryant traction. This type of traction does not maintain the leg in an extended position. It flexes the hip and knee at a 90-degree angle and suspends the leg in the air.
Choice C reason: This is not a correct description of Bryant traction. This type of traction does not use a sling under the knee of the affected leg. It uses a spreader bar to keep the legs apart and prevent rotation.
Choice D reason: This is a correct description of Bryant traction. This type of traction elevates the buttocks slightly off of the bed to provide countertraction and alignment of the fractured bone.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B"]
Explanation
Choice A reason: Polyuria, or excessive urination, is not a sign of low blood glucose level, but of high blood glucose level. It is caused by osmotic diuresis, which occurs when the kidneys try to flush out the excess glucose from the blood.
Choice B reason: Tachycardia, or fast heart rate, is a sign of low blood glucose level. It is caused by the activation of the sympathetic nervous system, which releases adrenaline and other hormones to increase the blood glucose level and stimulate the heart.
Choice C reason: Dry, flushed skin is not a sign of low blood glucose level, but of high blood glucose level. It is caused by dehydration, which occurs when the body loses fluid due to polyuria and increased thirst.
Choice D reason: Deep, rapid respirations are not a sign of low blood glucose level, but of diabetic ketoacidosis, a complication of high blood glucose level. It is caused by the accumulation of ketones, which are acidic substances produced when the body breaks down fat for energy due to lack of insulin.
Choice E reason: Hunger is a sign of low blood glucose level. It is caused by the lack of glucose in the cells, which are the main source of energy for the body. The brain signals the body to eat more to raise the blood glucose level.
Correct Answer is D
Explanation
Choice A reason: Using a 20 gauge needle is not the best action, as it is too large for a preschooler's deltoid muscle. A 20 gauge needle has a diameter of 0.9 mm, which may cause more pain and tissue damage. A smaller gauge needle, such as a 23 or 25 gauge, is recommended for intramuscular injections in children.
Choice B reason: Inserting the needle just below the acromion process is not the best action, as it may not reach the deltoid muscle. The acromion process is the bony prominence at the top of the shoulder. The deltoid muscle is located on the lateral aspect of the upper arm, about two finger widths below the acromion process. The nurse should palpate the acromion process and measure the distance to the injection site.
Choice C reason: Inserting the needle at a 15 degree angle is not the best action, as it may not penetrate the muscle tissue. A 15 degree angle is used for intradermal injections, which are given into the dermis, the layer of skin below the epidermis. Intramuscular injections are given into the muscle tissue, which requires a 90 degree angle. The nurse should hold the syringe perpendicular to the skin and insert the needle quickly and firmly.
Choice D reason: Using a 1.8 mm (0.5 in) needle is the best action, as it is the appropriate length for a preschooler's deltoid muscle. The length of the needle should be based on the child's age, weight, and muscle mass. A 1.8 mm (0.5 in) needle is suitable for children who weigh less than 12 kg (26 lb). A longer needle, such as a 2.5 mm (1 in) needle, may be used for children who weigh more than 12 kg (26 lb).
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