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.

Answer and Explanation

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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Correct Answer is A

Explanation

Answer: A. Biopsy may rupture the encapsulated tumor and cause the cancer cells to spread.

Rationale:

A) Biopsy may rupture the encapsulated tumor and cause the cancer cells to spread: This is the primary reason why surgery is performed before a biopsy in cases of Wilms tumor. The tumor is usually encapsulated, and performing a biopsy could risk breaking the capsule, leading to the dissemination of cancer cells into surrounding tissues, which can worsen the prognosis.

B) Metal clips are surgically applied at the tumor site for exact marking for radiation: While marking the tumor site for radiation is important, it is not the primary reason for performing surgery before a biopsy. The main concern is about the potential for cancer cell spread during a biopsy procedure.

C) Surgery is necessary to stage the tumor and determine metastasis to other sites: Although staging is a critical aspect of cancer management, the urgency of avoiding tumor rupture and subsequent spread is more pressing in this context. The surgery may assist in staging, but that is not the primary reason for immediate surgical intervention.

D) The surgery provides a visualization of other pathology and dysfunction of the kidney: While the surgical procedure may provide additional information about the kidney's condition, the most significant concern regarding Wilms tumor is preventing tumor rupture and the consequent spread of cancer cells, making this option less relevant.

A. Have the child blow a cotton ball and have the parent catch it. B. Place a toy in the child's hands while listening to the breath sounds. C. Oﬀer the child bubbles before the stethoscope is placed. D. Allow the child to use a stethoscope on a stuﬀed animal.

Correct Answer is D

Explanation

To ensure the cooperation of a preschooler during an assessment of lung sounds, the nurse can allow the child to use a stethoscope on a stuﬀed animal. This helps the child understand what is happening and feel more comfortable with the procedure. Having the child blow a cotton ball (A), placing a toy in the child's hands (B), and oﬀering bubbles (C ) may distract the child but do not directly involve them in the procedure.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The parents of a child with Wilms tumor ask the nurse why surgery is necessary before a biopsy is performed. Which information should the nurse provide?

Correct Answer is A

Explanation

The nurse is assessing the lung sounds of a preschooler. Which action should the nurse implement to ensure the child's cooperation?

Correct Answer is D

Explanation

The nurse is caring for an infant who was recently diagnosed with a congenital heart defect. Which assessment finding is most important for the nurse to report to the healthcare provider?

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When advising a new mother on caring for a child with croup, which symptom should be a priority concern for the telephone triage nurse?

The nurse is providing teaching to a school-age child with left femoral osteomyelitis and the child's parent prior to discharge. Which instruction should the nurse provide related to the initial phase of treatment?