When providing care for a child who is 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?
Cleanse pin sites as prescribed.
Monitor peripheral pulses and sensation in the right leg.
Assess skin for redness and signs of tissue breakdown.
Change position every 2 hours.
The Correct Answer is B
A. Cleansing pin sites as prescribed is important for infection prevention, but it is not the most critical intervention in the context of assessing vascular and neurologic status.
B. Monitor peripheral pulses and sensation in the right leg.
Balanced suspension skeletal traction is used to stabilize fractures or treat certain orthopedic conditions. Monitoring peripheral pulses and sensation in the right leg is a critical aspect of caring for a child in this type of traction. It is essential to ensure that the child's circulation and nerve function are not compromised. Changes in peripheral pulses and sensation can indicate potential complications, such as compromised blood flow or nerve compression, which need immediate attention to prevent further damage.
C. Assessing skin for redness and signs of tissue breakdown is important for skin care and preventing pressure ulcers, but it is secondary to monitoring peripheral pulses and sensation when the child is in traction.
D. Changing position every 2 hours is a standard nursing practice to prevent pressure ulcers and provide comfort, but it does not take precedence over monitoring circulation and sensation in the affected limb.
Peripheral pulses and sensation must be closely monitored and documented at regular intervals to ensure the child's safety and the effectiveness of the traction. Any changes in these parameters should be promptly reported to the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Correct answer: D
A.This can be a good distraction technique, but it might not directly facilitate the lung sound assessment.
B.This activity might help engage the child but could make it difficult for the nurse to listen to breath sounds accurately.
C.Holding a toy might keep the child occupied but does not directly relate to the assessment process and might not ensure cooperation as effectively as using a stethoscope on a stuffed animal.
D.Allowing the child to use the stethoscope on a stuffed animal can help reduce fear and anxiety by making the procedure more familiar and less intimidating. It engages the child in a playful and interactive manner, helping to build trust and cooperation.
Correct Answer is {"dropdown-group-1":"B"}
Explanation
Across the ventricular septum: This clarifies the location of the shunt, indicating that it occurs across the ventricular septum, leading to the mixing of oxygenated and deoxygenated blood.
So, the complete statement is: "Based on the child's diagnosis, he has mixed blood flow due to a left-to-right shunt across the ventricular septum."
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
