A 10-year-old child is receiving skeletal traction for a femur fracture and has metal pins inserted through the femur attached to traction weights.
During the morning assessment, the nurse notes slight redness around the pin sites with no drainage.
The child denies pain, and vital signs are stable.
What is the nurse's best action to ensure appropriate pin site care and prevent complications?
Notify the healthcare provider immediately and request antibiotics.
Remove crusting around the pin sites to allow for better drainage.
Cleanse the pin sites using sterile saline and assess for signs of infection.
Document findings as normal and continue routine assessments.
The Correct Answer is C
Choice A rationale
Notifying the healthcare provider immediately and requesting antibiotics is premature. Slight redness around pin sites without drainage or pain, and stable vital signs, does not immediately indicate a significant infection requiring systemic antibiotics. This initial finding warrants a thorough assessment and local care before escalating to medical intervention.
Choice B rationale
Removing crusting around pin sites can be detrimental. Crusting can serve as a protective barrier. Aggressive removal can introduce bacteria into the pin tract, increasing the risk of infection, or cause unnecessary pain and trauma to the delicate healing tissue. Gentle cleansing is preferred over forceful removal of adherent crusts.
Choice C rationale
Cleansing the pin sites using sterile saline and assessing for signs of infection is the best immediate action. Slight redness without drainage is often a normal inflammatory response to the foreign body and movement. Sterile saline effectively cleanses without irritating the tissue, and continued assessment helps monitor for evolving signs like increased redness, purulent drainage, or fever.
Choice D rationale
Documenting findings as normal and continuing routine assessments is insufficient. While slight redness can be normal, it still requires diligent monitoring and appropriate pin site care to prevent potential complications. Assuming normalcy without active intervention like cleansing could allow a minor irritation to progress to a more serious infection. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Focusing only on the area around the nipples is insufficient for a comprehensive self-breast exam. Breast tissue extends broadly from the collarbone to the bottom of the rib cage and from the armpit to the breastbone. Limiting the exam to one area could lead to missed abnormalities in other regions.
Choice B rationale
Using the pads of the fingers with varying pressure allows for thorough palpation of all breast tissue. Light pressure assesses superficial tissue, medium pressure evaluates deeper tissue, and firm pressure reaches the tissue closest to the chest wall, ensuring complete coverage and detection of abnormalities.
Choice C rationale
While lying down is one recommended position, conducting the exam only in this position is not sufficient. Performing the exam both lying down and standing (e.g., in the shower) allows for different tissue distributions and helps in detecting abnormalities that might be more palpable in one position over another.
Choice D rationale
Performing the exam every day is too frequent and unnecessary. Breast tissue changes throughout the menstrual cycle, and daily exams might lead to confusion regarding normal physiological variations. Monthly self-breast exams are recommended for consistency and to establish a baseline for individual breast tissue.
Correct Answer is A
Explanation
Choice A rationale
According to Erik Erikson's theory of psychosocial development, adolescence (roughly ages 12-18) is characterized by the central crisis of identity versus role confusion. During this stage, adolescents explore various roles, beliefs, and values to form a cohesive sense of self and define their place in society, integrating past experiences with future aspirations.
Choice B rationale
Autonomy versus shame and doubt is the psychosocial crisis associated with early childhood, typically ages 1-3 years. During this stage, children develop a sense of personal control over physical skills and a sense of independence. Successful resolution leads to autonomy, while failure can result in feelings of shame and self-doubt.
Choice C rationale
Trust versus mistrust is the psychosocial crisis of infancy, typically ages 0-1 year. In this stage, infants develop a sense of trust in caregivers and the world based on the consistency and reliability of care received. Successful resolution fosters hope and security, while neglect can lead to mistrust and anxiety.
Choice D rationale
Industry versus inferiority is the psychosocial crisis characteristic of school age, typically ages 6-12 years. Children at this stage are focused on developing competence and mastering academic and social skills. Success in these endeavors leads to a sense of industry, while difficulties can result in feelings of inferiority and low self-esteem.
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