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.
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Related Questions
Correct Answer is A
Explanation
The nurse should report the findings of significant erythema and swelling in the scrotum immediately to the healthcare provider. The adolescent's symptoms may be indicative of testicular torsion, which is a medical emergency and requires prompt treatment to prevent loss of the testicle. Obtaining a swab of secretions from the penis and urethra or collecting a sterile urine sample for culture and sensitivity are not appropriate actions for this presentation. Providing a urinal for urinary hesitancy may be appropriate if the adolescent is experiencing difficulty urinating, but this should not take precedence over reporting the findings to the healthcare provider.
Correct Answer is B
Explanation
The adolescent's symptoms suggest that their blood glucose levels may be very high. Obtaining a point-of- care glucose reading is the first step in assessing the adolescent's current blood glucose levels and determining the appropriate course of action.
Reviewing prior insulin prescriptions, assessing urine for ketones, and checking blood pressure are also important interventions but should occur after the blood glucose level has been determined.
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