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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Information about the child's reactions to any previous hospitalizations would be particularly helpful in planning care for this six-year-old girl who is being admited for repair of an umbilical hernia. This information can help the nurse anticipate and address any fears or concerns the child may have about the hospitalization and procedure.
A list of achievement timeline for developmental milestones is not particularly relevant in this situation.
A history of rubella, rubeola, or chicken pox is not particularly relevant in this situation.
Information about the mother's use of alcohol, drugs, or cigaretes during pregnancy is not particularly relevant in this situation.
Correct Answer is D
Explanation
The absence of continuous headaches in the child indicates that the VP shunt is functioning normally. A VP shunt is used to treat hydrocephalus by draining excess cerebrospinal fluid from the brain to the abdomen. If the shunt is functioning properly, it should relieve pressure on the brain and reduce symptoms such as headaches. The other options (A, B, and C) do not directly indicate whether the shunt is functioning normally or not.
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