A client who had a surgical fractured femur repair reports new-onset shortness of breath and increased respirations. What is the nurse’s first action?

Place the client in a high-Fowler position.

Document the client’s oxygen saturation level.

Start oxygen therapy at 2 L/min via nasal cannula.

Contact the primary health care provider.

Answer and Explanation

The Correct Answer is B

Choice A reason: Placing the client in a high-Fowler position may improve breathing but does not assess the cause of shortness of breath. Post-femur repair, pulmonary embolism (PE) is a risk due to fat emboli or thromboembolism, requiring objective data like oxygen saturation first.
Choice B reason: New-onset shortness of breath and tachypnea post-femur repair suggest possible pulmonary embolism or fat embolism syndrome. Documenting oxygen saturation provides objective data to assess hypoxia severity, guiding urgent interventions and communication with the healthcare provider for suspected life-threatening conditions.
Choice C reason: Starting oxygen therapy assumes hypoxia without confirmation. While it may be needed, assessing oxygen saturation first ensures the intervention is appropriate. Unwarranted oxygen administration could delay critical diagnostic steps for conditions like pulmonary embolism, which require anticoagulation or other therapies.
Choice D reason: Contacting the provider is important but secondary to assessing oxygen saturation, which provides critical data to report. Without objective findings, the nurse cannot convey the urgency or specifics of the client’s condition, potentially delaying life-saving interventions for suspected embolism.

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Correct Answer is A

Explanation

Choice A reason: Heels against the bed in Buck’s traction cause pressure, risking skin breakdown or ulcers, especially in children with sensitive skin. This requires intervention (e.g., repositioning or padding) to prevent tissue damage and ensure traction maintains fracture alignment without complications.
Choice B reason: Elevating the head of the bed 20 degrees is acceptable in Buck’s traction, as it promotes comfort and does not disrupt the traction’s alignment or force. It is not a concern requiring intervention unless it affects traction mechanics.
Choice C reason: Freely hanging weights are correct in Buck’s traction, ensuring consistent force to align the fracture. This is a desired observation, as obstructed weights would disrupt traction efficacy, and no intervention is needed for this finding.
Choice D reason: Ropes on pulleys are essential for Buck’s traction to function, allowing smooth force transmission to align the fracture. This is a correct setup, requiring no intervention, as it ensures the traction system operates effectively without mechanical issues.

A. Infants are in a supine or prone position most of the time. B. Sucking on a nipple creates middle ear pressure. C. They have increased susceptibility to upper respiratory tract infections. D. The eustachian tube is short, straight, and wide.

Correct Answer is D

Explanation

Choice A reason: A supine or prone position may allow milk or secretions to pool, but this is not the primary reason for otitis media susceptibility. Positioning contributes indirectly by facilitating fluid reflux, but anatomical factors are more significant in infants.
Choice B reason: Sucking on a nipple does not significantly create middle ear pressure. While bottle-feeding in a supine position may allow fluid reflux into the eustachian tube, this is secondary to the anatomical structure of the tube itself.
Choice C reason: Infants are prone to upper respiratory infections due to immature immunity, which can lead to otitis media. However, this is a contributing factor, not the primary anatomical reason, as infections exploit the eustachian tube’s structure to cause middle ear inflammation.
Choice D reason: Infants’ eustachian tubes are shorter, straighter, and wider than in adults, allowing easier passage of bacteria from the nasopharynx to the middle ear. This anatomical feature impairs drainage and ventilation, increasing susceptibility to fluid accumulation and infection, making it the primary cause.

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A client who had a surgical fractured femur repair reports new-onset shortness of breath and increased respirations. What is the nurse’s first action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

On entering the room of a child in Buck’s traction, the nurse makes all of the following observations. Which observation requires a nursing intervention?

Correct Answer is A

Explanation

Why are infants more susceptible to otitis media?

Correct Answer is D

Explanation

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