When providing care for a child in balanced suspension skeletal traction using a Thomas splint and Pearson attachment to the right femur, which intervention is most important for the nurse to implement?
Change position every 2 hours.
Monitor peripheral pulses and sensation in the right leg.
Cleanse pin sites as prescribed.
Assess skin for redness and signs of tissue breakdown.
The Correct Answer is B
When caring for a child in balanced suspension skeletal traction, the most important intervention for the nurse to implement is monitoring peripheral pulses and sensation in the affected leg to detect any compromise in circulation or nerve function. This is crucial because the traction places tension on the bones, which can result in nerve or vascular damage.
Changing positions every 2 hours is important to prevent pressure injuries, but it is not the most critical intervention.
Cleansing pin sites and assessing skin for redness and signs of tissue breakdown are also important, but they are not as urgent as monitoring peripheral pulses and sensation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1"]
Explanation
1 teaspoon.
The child has been prescribed loratadine 5 mg once a day. The botle is labeled "Loratadine for Oral Suspension, USP 5 mg per 5 mL." This means that for every 5 mL of the suspension, there is 5 mg of loratadine. Since 1 teaspoon is equivalent to 5 mL, the nurse should instruct the parent to administer 1 teaspoon with each dose to provide the prescribed 5 mg of loratadine.
Correct Answer is A
Explanation
The nurse should inspect the posterior oropharynx of a child who is frequently swallowing after tonsillectomy to assess for bleeding or the presence of clots. Swallowing frequently can be a sign of postoperative bleeding, which is a potential complication of tonsillectomy.
Touching the tonsillar pillars to stimulate the gag reflex or asking the child to speak would not provide information about the presence of bleeding.
Assessing for teeth clenching or grinding is not related to this particular observation.
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