The nurse is caring for a child with a fracture who is placed in skeletal traction. The nurse monitors for the most serious complication associated with this type of traction by checking for which?
An increase in the blood pressure
An elevated temperature
A decrease in urine output
A lack of appetite
The Correct Answer is B
B. The most serious complication associated with skeletal traction is osteomyelitis, an infection that involves the bone. This condition can occur when organisms gain access to the bone either systemically or through the openings created by the metal pins or wires used in the traction.
A. Increased blood pressure can occur for various reasons but it is not the most serious complication associated with skeletal traction.
C. A decrease in urine output could indicate systemic infection which is a late feature of osteomyelitis and therefore, not the earliest to monitor.
D. Changes in appetite can occur in response to pain or stress but they are not typically the most serious complication associated with skeletal traction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This option is the most appropriate choice for an infant with respiratory syncytial virus (RSV). RSV is highly contagious and primarily spreads through respiratory secretions. Placing the infant in a private room helps to minimize the risk of transmission to other patients. Contact and droplet precautions should be implemented to further prevent the spread of the virus.
B. This choice is not ideal because both RSV and croup are respiratory infections that can spread easily among infants. Placing an infant with RSV in a semi-private room with another infant increases the risk of transmission of both infections to each other.
C. While isolating the infant in a private room is appropriate for preventing the spread of RSV, the term "protective isolation" typically refers to a type of isolation used for patients who have compromised immune systems.
D. Placing the infant with RSV in a semi-private room with a toddler who has pneumonia is not recommended. Both RSV and pneumonia are respiratory infections that can spread easily among patients, especially infants and young children who are more susceptible to complications.
Correct Answer is A
Explanation
A. The absence of the dorsalis pedis pulse in the right foot is concerning and could indicate compromised circulation to the extremity. It is essential to notify the healthcare provider promptly so that further assessment and intervention can be initiated to address the circulation issue and prevent potential complications such as ischemia or tissue damage.
B. Administering an analgesic may be necessary to manage the child's pain, especially if they are experiencing discomfort due to the femur fracture. However, addressing the absent dorsalis pedis pulse takes priority as it suggests a potential vascular problem that requires immediate attention.
C. Releasing the skin traction may not be appropriate at this point without further assessment and guidance from the healthcare provider. Skin traction is often used to temporarily stabilize fractures and reduce pain, and releasing it without proper evaluation could potentially exacerbate the injury or compromise the child's comfort and stability.
D. Applying ice to the extremity is not indicated in this situation. Ice application is typically used for acute injuries to reduce swelling and inflammation, but it is not appropriate when there is concern about compromised circulation.
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