A child has a right femur fracture caused by a motor vehicle crash and is placed in skin traction temporarily until surgery can be preformed. During assessment, the nurse notes that the dorsalis pedis pulse is absent on the right foot. Which action should the nurse take?
Notify the health care provider (HCP)
Administer an analgesic
Release the skin traction
Apply ice to the extremity
The Correct Answer is A
A. The absence of the dorsalis pedis pulse in the right foot is concerning and could indicate compromised circulation to the extremity. It is essential to notify the healthcare provider promptly so that further assessment and intervention can be initiated to address the circulation issue and prevent potential complications such as ischemia or tissue damage.
B. Administering an analgesic may be necessary to manage the child's pain, especially if they are experiencing discomfort due to the femur fracture. However, addressing the absent dorsalis pedis pulse takes priority as it suggests a potential vascular problem that requires immediate attention.
C. Releasing the skin traction may not be appropriate at this point without further assessment and guidance from the healthcare provider. Skin traction is often used to temporarily stabilize fractures and reduce pain, and releasing it without proper evaluation could potentially exacerbate the injury or compromise the child's comfort and stability.
D. Applying ice to the extremity is not indicated in this situation. Ice application is typically used for acute injuries to reduce swelling and inflammation, but it is not appropriate when there is concern about compromised circulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. The aim is to focus on the child's strengths and abilities while addressing limitations and challenges associated with the condition. This approach emphasizes maximizing the child's potential for development, independence, and participation in daily activities, education, and social interactions, while also providing support and resources to address any limitations or barriers they may encounter.
A. Another goal of treatment and care is to maximize the child's functional abilities by improving muscle control, coordination, and mobility through various therapies, such as physical therapy, occupational therapy, and speech therapy. However, this is not the primary goal.
B. Cerebral palsy is a neurological condition caused by damage to the developing brain, often occurring before birth. While efforts to prevent cerebral palsy are important, once the condition has developed, the focus shifts to managing symptoms and optimizing the child's functioning rather than eliminating the cause.
C. Emotional well-being is an important aspect of overall health for children with cerebral palsy but it is not typically the primary goal of care. Emotional disturbances may occur in some children with cerebral palsy due to various factors such as coping with the challenges of the condition, social interactions, or other comorbidities, but the primary focus of the care plan is usually on addressing physical and functional impairments.
Correct Answer is ["1.5"]
Explanation
Volume= Desired dose/ concentration in mg/ml Concentration per ml= 10mg/ml
Desired dose= 15mg Volume= 15mg/10mg/ml Volume = 1.5ml
Therefore, the nurse should administer 1.5ml of morphine
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