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

Peripheral intravenous (IV) infusion is a common procedure performed on infants in a hospital setting. The selection of the IV site is critical to ensure proper placement and to prevent complications.

When starting a peripheral IV infusion on an infant, the nurse should select a site that is least restrictive to the infant. This involves selecting a site that will not restrict the infant's movement and cause discomfort. The site should be accessible, visible, and easily palpable, such as the hand, wrist, or antecubital fossa.

Assessing the dorsal surface of the feet for an IV site is not recommended as it is an area of high risk for infiltration and may restrict the infant's movement.

Instructing parents to sing or croon to the infant may provide comfort and distraction, but it is not a critical intervention when starting a peripheral IV infusion.

Applying soft restraints to all four extremities is not recommended as it may cause physical and emotional distress to the infant. It should only be used as a last resort if the infant is at high risk of self-injury or if the procedure cannot be safely performed without restraints.

Therefore, the nurse should implement the intervention of selecting a site that is least restrictive to the infant when starting a peripheral IV infusion.

A. Ibuprofen should be used prophylactically to prevent febrile seizures. B. Provide the child with a sponge bath for temperatures over 100.6°F (38.1° C. Reassure the parents that febrile seizures decrease as the child grows older. D. Avoid excessive visual stimuli because it can precipitate seizure activity.

Correct Answer is C

Explanation

The nurse should reassure the parents that febrile seizures typically decrease in frequency as the child grows older. Most children outgrow febrile seizures by the age of 5 years.

Ibuprofen is not typically used prophylactically to prevent febrile seizures.

Providing the child with a sponge bath for temperatures over 100.6°F (38.1° C) can help to lower the fever, but it will not necessarily prevent febrile seizures.

Avoiding excessive visual stimuli is not necessary for children with febrile seizures, as this type of seizure is triggered by a fever rather than visual stimuli.

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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

When starting a peripheral intravenous (IV) infusion on an infant, which intervention should the nurse implement?

Correct Answer is A

Explanation

The parents of a 14-month-old child who is hospitalized due to febrile seizures tell the nurse that they fear their child will have lifelong seizures. Which information should the nurse convey to these parents?

Correct Answer is C

Explanation

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

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