A nurse is developing a plan of care for a child who is in skeletal traction following a femur fracture. Which of the following actions should the nurse include in the plan?

Lift the traction weights when repositioning the child in bed.

Have the child rate their level of pain ever-8 hr.

Monitor the neurovascular status of the child's lower extremities every 12 hr.

Educate the child's guardians about pin site care prior to discharge.

Answer and Explanation

The Correct Answer is D

A. Lift the traction weights when repositioning the child in bed.

This action should not be included in the plan of care because lifting the traction weights can interfere with the traction's effectiveness and potentially cause harm or injury to the child. The weights are specifically calibrated to provide the necessary tension for the traction to stabilize the fracture site.

B. Have the child rate their level of pain every 8 hours.

While pain assessment is an essential component of nursing care, the frequency of every 8 hours may not be sufficient, especially for a child in skeletal traction. Pain management should be more frequent and individualized based on the child's needs, which may vary throughout the day.

C. Monitor the neurovascular status of the child's lower extremities every 12 hours.

Neurovascular assessment is crucial for patients in traction to detect any signs of compromised circulation or nerve function. However, every 12 hours may not be frequent enough to promptly identify changes in neurovascular status. More frequent assessments, such as every 1-2 hours initially and then gradually decreasing based on stability, are typically recommended.

D. Educate the child's guardians about pin site care prior to discharge.

This is the correct answer. Educating the child's guardians about pin site care is essential to prevent infection and other complications associated with skeletal traction. Proper care of the pin sites reduces the risk of infection, which can lead to serious complications such as osteomyelitis. Providing education prior to discharge ensures that the guardians are equipped with the necessary knowledge and skills to care for the child at home effectively.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Measure the legs with a tape measure to determine stocking size: Antiembolic stockings should fit properly to provide therapeutic compression without causing discomfort or impairing circulation. Measuring the legs accurately with a tape measure ensures the stockings fit appropriately and exert the correct amount of pressure to prevent deep vein thrombosis (DVT) and promote venous return.
B. Remove the stockings every 24 hr: Antiembolic stockings are typically worn continuously, especially during periods of immobility, to maintain consistent compression and prevent blood clots. Removing the stockings every 24 hours would interrupt the therapeutic effect and increase the client's risk of developing DVT.
C. Massage the legs before applying the stockings: Massaging the legs before applying antiembolic stockings is contraindicated, as it can dislodge blood clots and increase the risk of embolism. Additionally, massaging may cause trauma to the skin and exacerbate any existing circulatory issues.
D. Fold the stockings at the top if they are too long: Folding the stockings at the top if they are too long can create pressure points and compromise circulation, leading to discomfort and potentially exacerbating vascular issues. It is essential to ensure the stockings fit properly by selecting the appropriate size rather than folding them.

A. "Incident report completed. A copy will be placed in the client's medical record. B. "Prescribed dressing change was accidentally omitted during the previous shift." C. "A nurse accidentally omitted a prescribed dressing change. Will notify the provider tomorrow." D. "Unable to complete a prescribed dressing change. However, dressing did not appear to be soiled.

Correct Answer is B

Explanation

A. "Incident report completed. A copy will be placed in the client's medical record." This statement indicates the completion of the incident report but lacks essential information about what incident occurred. It does not provide details necessary for understanding the nature of the incident.
B. "Prescribed dressing change was accidentally omitted during the previous shift." This statement clearly identifies the nature of the incident, stating that a prescribed dressing change was missed. It provides factual information without assigning blame, which is appropriate for an incident report.
C. "A nurse accidentally omitted a prescribed dressing change. Will notify the provider tomorrow." While this statement acknowledges the omission, it lacks details about the incident and focuses on future actions rather than accurately documenting what occurred.
D. "Unable to complete a prescribed dressing change. However, dressing did not appear to be soiled." This statement does not accurately represent the situation. It implies that the dressing change was not completed due to the dressing not appearing soiled, which may not be the case. It does not acknowledge the omission of the prescribed dressing change.

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A nurse is developing a plan of care for a child who is in skeletal traction following a femur fracture. Which of the following actions should the nurse include in the plan?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has deep-vein thrombosis and a new prescription for antiembolic stockings. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is creating an incident report due to an accidental omission of a client's dressing change during the previous shift. Which of the following statements should the nurse document on the incident report form?

Correct Answer is B

Explanation

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