A 6-year-old with a fractured femur is in Russell’s traction. Surgical intervention to correct the fracture is scheduled for the morning. Nursing actions should include which action?
Releasing traction every hour to perform skin care.
Releasing traction once every 8 hours to check circulation.
Maintaining continuous traction until 1 hour before the scheduled surgery.
Maintaining continuous traction and checking the position of traction.
The Correct Answer is D
Choice A reason:
Releasing traction every hour to perform skin care: Releasing traction every hour is not recommended as it can disrupt the alignment and healing process of the fractured femur. Skin care is important, but it should be performed without compromising the traction setup.
Choice B Reason:
Releasing traction once every 8 hours to check circulation: While checking circulation is crucial, releasing traction every 8 hours is not necessary and can interfere with the therapeutic benefits of traction. Circulation can be monitored without releasing the traction.
Choice C Reason:
Maintaining continuous traction until 1 hour before the scheduled surgery: Continuous traction is essential to maintain the alignment of the fractured femur. However, there is no need to release traction 1 hour before surgery unless specifically instructed by the surgical team.
Choice D Reason:
Maintaining continuous traction and checking the position of traction: This is the most appropriate action. Continuous traction ensures proper alignment and healing of the fractured femur. Regularly checking the position of traction helps prevent complications and ensures the effectiveness of the treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Cardiac arrhythmia is a primary clinical manifestation of hyperkalemia. Hyperkalemia, defined as an elevated level of potassium in the blood, can significantly affect the electrical activity of the heart. This can lead to various types of arrhythmias, including bradycardia, ventricular tachycardia, and even cardiac arrest1. The presence of arrhythmias is a critical indicator of hyperkalemia and requires immediate medical attention to prevent life-threatening complications.
Choice B reason:
Seizures are not typically associated with hyperkalemia2. While severe electrolyte imbalances can potentially lead to neurological symptoms, seizures are more commonly linked to conditions such as hyponatremia (low sodium levels) or hypocalcemia (low calcium levels). Therefore, seizures are not a primary sign of hyperkalemia.
Choice C reason:
Dyspnea, or difficulty breathing, can occur in various medical conditions, including heart failure and respiratory disorders. While hyperkalemia can lead to muscle weakness and fatigue, which might indirectly affect breathing, dyspnea is not a primary clinical manifestation of hyperkalemia. The main concern with hyperkalemia is its effect on cardiac function.
Choice D reason:
Oliguria, or reduced urine output, is a symptom of acute renal failure but not specifically indicative of hyperkalemia. While acute renal failure can lead to hyperkalemia due to the kidneys’ inability to excrete potassium, oliguria itself is not a direct sign of hyperkalemia. The focus should be on the cardiac effects of elevated potassium levels
Correct Answer is ["2"]
Explanation
Calculation Steps
Step 1: Determine the total urine output in mL.
- Total urine output = 360 mL
Step 2: Determine the child’s weight in kg.
- Weight = 15 kg
Step 3: Determine the time period in hours.
- Time = 12 hours
Step 4: Calculate the urine output in mL/kg/hour.
- Urine output (mL/kg/hour) = Total urine output ÷ (Weight × Time)
Step 5: Perform the multiplication inside the parentheses first.
- Weight × Time = 15 kg × 12 hours = 180 kg·hours
Step 6: Perform the division.
- Urine output (mL/kg/hour) = 360 mL ÷ 180 kg·hours = 2 mL/kg/hour
Result
The child’s urine output is 2 mL/kg/hour.
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