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. Place resuscitation equipment at the child's bedside. This is because epiglottitis can lead to a life- threatening emergency requiring immediate intervention, and having resuscitation equipment readily available is essential for rapid response.
A. Establishing intravenous access may be necessary for administering fluids and medications but it is not the nurse's priority action when caring for a child with suspected epiglottitis.
B. Droplet precautions help reduce the risk of transmission of respiratory pathogens to others. However, the priority is to address the child's respiratory distress and potential airway compromise.
C. Providing blow-by humidified oxygen can be beneficial in managing the child's respiratory status. However, securing the airway takes precedence over other interventions, as indicated by the guidelines for managing epiglottitis.
Correct Answer is A
Explanation
A. This statement indicates that the mother understands the purpose of giving pancreatic enzymes to her child with cystic fibrosis. Cystic fibrosis can cause pancreatic insufficiency, leading to difficulty digesting fats and other nutrients. Pancreatic enzymes help to supplement the deficient digestive enzymes, aiding in the digestion of fats and improving nutrient absorption.
B. Pancreatic enzyme capsules are typically meant to be swallowed whole, not chewed. Chewing the capsules could affect their effectiveness by prematurely releasing the enzymes in the mouth rather than in the stomach where they are needed for digestion.
C. While pancreatic enzymes can help with digestion and may indirectly reduce symptoms like nausea by improving nutrient absorption, their primary purpose is not to prevent nausea.
D. Pancreatic enzymes are usually taken with meals or snacks to aid in the digestion of food. The timing of pancreatic enzyme administration may vary depending on the child's eating schedule and the specific instructions provided by the healthcare provider, but taking them 2 hours before meals would not typically be recommended.
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