A nurse is caring for a child who has Legg-Calve-Perthes disease and is in Buck extension traction.
Which of the following actions should the nurse take?
Reposition the child every 2 hr.
Remove the traction boot during baths.
Reduce fluid intake.
Apply antibiotic ointment to pin sites daily.
The Correct Answer is A
The correct answer is choice a. Reposition the child every 2 hr.
Choice A rationale:
Repositioning the child every 2 hours is essential to prevent complications such as pressure ulcers and to promote comfort and circulation.
Choice B rationale:
Removing the traction boot during baths is not recommended as it can disrupt the traction setup and potentially worsen the condition.
Choice C rationale:
Reducing fluid intake is not necessary for managing Legg-Calve-Perthes disease and could lead to dehydration.
Choice D rationale:
Applying antibiotic ointment to pin sites daily is not applicable in this scenario as Buck extension traction typically does not involve pin sites.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Normal urine output for a child is 1-2 ml/kg/hr.
The child weighs 33 lb (15 kg), so their expected urine output over an 8-hour period would be between 120 mL and 240 mL.
The child’s urine output of 160 mL falls within this range.
Choice A, Notifying the provider, is not necessary because the child’s urine output
is within the normal range.
Choice C, Perform a bladder scan at the bedside, is not necessary because there is no indication of urinary retention.
Choice D, Providing oral rehydration fluids, is not necessary because the child’s urine output is within the normal range.
Correct Answer is A
Explanation
Nursing care planning goals for a child with acute glomerulonephritis are directed toward the excretion of excess fluid through urination.
Monitoring fluid status is very important and daily weights are an effective way to monitor fluid retention, as weight gain is the earliest sign of fluid retention.
Choice B, Educating the parents about potential complications, is important but not the nurse’s priority.
Choice C, Place the child on a no-salt-added diet, which may be part of the treatment
plan but is not the nurse’s priority.
Choice D, Maintaining a saline lock, may be necessary for administering medications but is not the nurse’s priority.
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