On entering the room of a child in Buck’s traction, the nurse makes all of the following observations. Which observation requires a nursing intervention?

Child’s heels are placed firmly against the foot of the bed.

Head of bed is elevated 20 degrees.

Weights are hanging freely.

Ropes are on pulleys.

Answer and Explanation

The Correct Answer is A

Choice A reason: Heels against the bed in Buck’s traction cause pressure, risking skin breakdown or ulcers, especially in children with sensitive skin. This requires intervention (e.g., repositioning or padding) to prevent tissue damage and ensure traction maintains fracture alignment without complications.
Choice B reason: Elevating the head of the bed 20 degrees is acceptable in Buck’s traction, as it promotes comfort and does not disrupt the traction’s alignment or force. It is not a concern requiring intervention unless it affects traction mechanics.
Choice C reason: Freely hanging weights are correct in Buck’s traction, ensuring consistent force to align the fracture. This is a desired observation, as obstructed weights would disrupt traction efficacy, and no intervention is needed for this finding.
Choice D reason: Ropes on pulleys are essential for Buck’s traction to function, allowing smooth force transmission to align the fracture. This is a correct setup, requiring no intervention, as it ensures the traction system operates effectively without mechanical issues.

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Correct Answer is C

Explanation

Choice A reason: Green-blue discharge suggests infection, possibly bacterial (e.g., Pseudomonas), but is not specific to tympanic membrane rupture. In otitis media with effusion, discharge may occur with perforation, but the color is not diagnostic of rupture itself.
Choice B reason: Increased temperature is common in otitis media due to infection but does not specifically indicate tympanic membrane rupture. Fever reflects systemic inflammation, not the mechanical event of perforation, which is better indicated by other symptoms.
Choice C reason: Sudden pain relief in otitis media with effusion occurs when a tympanic membrane rupture releases pressure from fluid buildup in the middle ear. This alleviates the intense pain caused by pressure on the membrane, making it a hallmark sign of perforation.
Choice D reason: A popping sensation when swallowing may occur due to eustachian tube dysfunction but is not specific to tympanic membrane rupture. It reflects pressure changes in the middle ear, not the acute event of perforation.

A. Guide the child to the floor if the child is standing, and then go for help. B. Move objects out of the child’s immediate area. C. Stick a padded tongue blade between the child’s teeth. D. Manually restrain the child.

Correct Answer is B

Explanation

Choice A reason: Guiding a child to the floor during a seizure is unsafe, as it risks injury to both the child and nurse due to uncontrolled movements. Leaving to get help abandons the child, increasing injury risk during the seizure’s tonic-clonic phase.
Choice B reason: Moving objects away from a child during a tonic-clonic seizure prevents injury from striking hard surfaces. Generalized seizures cause uncontrolled muscle contractions, increasing the risk of trauma. Ensuring a safe environment is a priority to minimize harm during the seizure event.
Choice C reason: Inserting a tongue blade, even padded, risks dental injury or airway obstruction, as jaw clenching is common in tonic-clonic seizures. Current guidelines advise against placing objects in the mouth, as it does not prevent tongue biting and may cause harm.
Choice D reason: Restraining a child during a seizure can cause fractures or soft tissue injury due to forceful muscle contractions. It also increases stress and hypoxia risk. Allowing the seizure to occur while ensuring safety is the recommended approach to minimize complications.

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On entering the room of a child in Buck’s traction, the nurse makes all of the following observations. Which observation requires a nursing intervention?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has otitis media with effusion. The nurse should identify that which of the following manifestations indicates a tympanic membrane rupture?

Correct Answer is C

Explanation

What is an appropriate nursing action when a child is experiencing a generalized tonic-clonic seizure?

Correct Answer is B

Explanation

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The nurse explains that Bryant's traction is reserved for children who weigh less than how many pounds?

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A nurse plans care for a client who has an external fixator on the lower leg. Which intervention would the nurse include in the plan of care to decrease the client’s risk for infection?