A nurse is caring for a child who is 2 hr postoperative.
Which of the following actions should the nurse take first? (Click the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)
Compare the child's pedal pulses.
Determine the child's sedation level.
Assess the child's pain level.
Recheck the child's temperature.
Correct Answer : A
Given the child's recent motor vehicle accident and subsequent orthopedic surgeries, assessing the peripheral circulation is crucial. Comparing pedal pulses helps to determine the adequacy of blood flow to the lower extremities and identify any potential complications such as compartment syndrome. This assessment should be prioritized immediately.
While assessing pain, sedation level, and rechecking temperature are all important, they do not take precedence over assessing the child's circulation and perfusion status following major orthopedic surgeries.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Lotions, powders, or ointments should be avoided under the harness as they can irritate the skin.
B. This helps protect the skin and keeps the harness clean.
C. Only a healthcare provider should adjust the harness straps. Parents should not attempt to do this.
D. Massage can irritate the skin and should be avoided.
Correct Answer is ["A"]
Explanation
Given the child's recent motor vehicle accident and subsequent orthopedic surgeries, assessing the peripheral circulation is crucial. Comparing pedal pulses helps to determine the adequacy of blood flow to the lower extremities and identify any potential complications such as compartment syndrome. This assessment should be prioritized immediately.
While assessing pain, sedation level, and rechecking temperature are all important, they do not take precedence over assessing the child's circulation and perfusion status following major orthopedic surgeries.
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