A nurse is providing care to a child who was placed in 90-90 skeletal traction 12 hr ago. Which of the following actions should the nurse take?
Encourage the child to use the trapeze bar for position changes.
Maintain the child's leg in an extended position while in traction.
Perform neurovascular assessment on the affected extremity every 4 hr.
Release the child's traction weights when changing bed linens.
The Correct Answer is A
Choice A reason: Encouraging the child to use the trapeze bar for position changes promotes mobility, independence, and prevents complications such as skin breakdown. It allows safe repositioning without disrupting traction alignment. This is the correct intervention.
Choice B reason: Maintaining the leg in an extended position is incorrect because 90-90 traction requires the hip and knee to be flexed at 90 degrees. Extending the leg would disrupt the traction setup and compromise healing.
Choice C reason: Neurovascular assessments should be performed more frequently than every 4 hours, especially in the first 24 hours after traction initiation. The standard is every 1–2 hours initially to detect early signs of impaired circulation. Therefore, every 4 hours is insufficient.
Choice D reason: Traction weights should never be released unless specifically ordered by the provider. Removing weights disrupts the traction system, compromises bone alignment, and increases the risk of complications. This makes the option unsafe.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: Clients do not need provider approval to sign advance directives. Advance directives are legal documents that reflect the client’s autonomy and do not require medical authorization.
Choice B reason: Clients do not need to contact the court to change a living will. They can revise or revoke their advance directives at any time as long as they are competent to make decisions.
Choice C reason: Appointing a health care surrogate is correct. This allows clients to designate someone to make medical decisions on their behalf if they become unable to do so, ensuring their wishes are respected even during periods of impaired judgment.
Choice D reason: Clients are not required to designate a guardian to initiate advance directives. Guardianship is a legal process separate from advance directives and is not necessary unless the client has been deemed legally incompetent.
Correct Answer is A
Explanation
Choice A reason: Infusing 0.9% sodium chloride IV is the correct action because it maintains venous access and prevents clotting while stopping the transfusion. Normal saline is the only compatible solution for flushing blood products. This intervention ensures the client remains stabilized while further treatment is initiated.
Choice B reason: Administering an antipyretic may reduce fever but does not address the underlying hemolytic reaction. The priority is to stop the transfusion and maintain IV access with normal saline. Antipyretics are supportive but not the immediate intervention.
Choice C reason: Decreasing the infusion rate to 75 mL/hr is inappropriate because the transfusion must be stopped immediately when a hemolytic reaction occurs. Continuing the transfusion, even at a slower rate, exposes the client to further hemolysis and complications such as renal failure or shock.
Choice D reason: Placing the client in a left lateral position does not address the hemolytic reaction. Positioning may be useful in other conditions (e.g., aspiration risk), but it is not relevant to transfusion reactions. The priority is stopping the transfusion and initiating supportive care.
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