A nurse is caring for a pediatric patient in skeletal traction for a femur fracture. Which nursing action is the highest priority to prevent complications associated with skeletal traction?

Ensure the weights hang freely and do not touch the floor to maintain proper traction force.

Remove the traction weights every 6 hours to prevent skin breakdown,

Limit monitoring of pin sites to once every 24 hours to reduce patient discomfort.

Place the rope knot in contact with the pulley to stabilize the traction system.

Answer and Explanation

The Correct Answer is A

A. Ensure the weights hang freely and do not touch the floor to maintain proper traction force is correct. Proper skeletal traction depends on continuous, consistent force applied through the weights. If the weights touch the floor or are obstructed, the traction is disrupted, which can result in malalignment, delayed healing, increased pain, or neurovascular compromise. Maintaining correct traction mechanics is the highest priority to prevent serious complications.

B. Remove the traction weights every 6 hours is incorrect because weights should never be removed unless prescribed. Interrupting traction can cause muscle spasm, malalignment, or delayed fracture healing. Skin breakdown is addressed through regular skin care and positioning, not by removing weights.

C. Limit monitoring of pin sites to once every 24 hours is incorrect because pin sites require frequent assessment (at least every 4–8 hours) for signs of infection, inflammation, or loosening. Infrequent monitoring increases the risk of osteomyelitis or local infection.

D. Place the rope knot in contact with the pulley is incorrect because this would interfere with the smooth functioning of the traction system. The rope must move freely through the pulley to maintain proper tension and alignment.

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Free Nursing Study Resources

Correct Answer is ["A","C","E"]

Explanation

A. Expression of bedtime fears is common is correct because toddlers commonly experience fears related to separation, darkness, or unfamiliar situations. These fears are a normal part of emotional and cognitive development and should be addressed with reassurance and consistent routines.

B. Importance of annual screenings for phenylketonuria is incorrect because PKU screening is performed at birth through newborn screening. Routine annual screening is not part of anticipatory guidance for toddlers.

C. Develop food habits that will prevent dental caries is correct because toddlers are at increased risk for dental caries. Guidance should include limiting sugary foods and drinks, avoiding bedtime bottles with milk or juice, and promoting good oral hygiene habits.

D. Significance of potty training by 18 months is incorrect because readiness for toilet training varies widely. Most toddlers are not developmentally ready until 18–24 months or later, and forcing early training can lead to frustration and setbacks.

A. Intussusception B. Pyloric stenosis C. A. Gastroesophageal reflux (GER) D. Hirschsprung's disease

Correct Answer is B

Explanation

A. Intussusception is incorrect because this condition typically presents with intermittent abdominal pain, drawing up of the legs, and “currant jelly” stools caused by blood and mucus. Vomiting may occur, but the presence of a palpable olive-shaped mass and projectile vomiting is not characteristic.

B. Pyloric stenosis is correct. Pyloric stenosis occurs when the pyloric muscle hypertrophies, causing gastric outlet obstruction. It usually presents in infants around 3–6 weeks of age with forceful, projectile vomiting immediately after feedings, signs of weight loss or poor weight gain, dehydration, and a palpable, firm, olive-shaped mass in the right upper abdomen. Vomiting is non-bilious because the obstruction is proximal to the duodenum.

C. Gastroesophageal reflux (GER) is incorrect because GER typically causes spitting up or regurgitation, which is usually non-forceful and not associated with an olive-shaped mass or significant weight loss. GER is common in infants and often resolves spontaneously.

D. Hirschsprung's disease is incorrect because it presents with chronic constipation, abdominal distension, and delayed passage of meconium in the newborn period. Projectile vomiting and a palpable pyloric mass are not typical features.

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A nurse is caring for a pediatric patient in skeletal traction for a femur fracture. Which nursing action is the highest priority to prevent complications associated with skeletal traction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing anticipatory guidance to the parents of a toddler. Which of the following should the nurse include? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

A 3-week-old infant is brought to the emergency department with a history of forceful, projectile vomiting after feedings and signs of weight loss. On assessment, the nurse palpates a small, olive-shaped mass in the upper abdomen. Which condition does this clinical picture most likely indicate?

Correct Answer is B

Explanation

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