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

Answer and Explanation

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.

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Correct Answer is C

Explanation

C. The priority during a seizure is to protect the patient from harm, particularly from aspiration if they vomit or have excessive saliva production. Turning the client to a lateral position helps maintain an open airway and prevents aspiration. This action should be taken immediately after lowering the client to the floor to ensure their safety.

A. Providing oxygen is important for a patient experiencing a seizure. However, it's not the first action to take. The priority is to ensure the patient's safety and protect them from injury during the seizure.

B. Administering anticonvulsant medication during an active seizure is not appropriate. Anticonvulsants are typically prescribed as maintenance therapy to prevent seizures or to manage seizure disorders in a controlled manner, not during an acute seizure episode.

D. Monitoring oxygen saturation is important but it's not the first action to take during an active seizure. Ensuring the patient's safety and protecting them from injury take precedence. Oxygen saturation can be assessed once the patient is in a safe position.

A. "Put an ice pack on the ankle, alternating 20 minutes on with 20 minutes off." B. "Wrap the ankle in an Ace bandage for support." C. "Keep the leg elevated when sitting" D. "Apply warm compresses to the ankle for the first 24 hours."

Correct Answer is D

Explanation

D. Warm compresses or heat therapy are not recommended for the initial management of a sprained ankle, especially within the first 24 hours. Heat can increase blood flow and exacerbate swelling and inflammation, which may worsen pain and delay healing.

A. Applying ice packs in this manner helps reduce inflammation and swelling, which are common after a sprain. Alternating ice application with periods of rest allows for effective cooling without causing tissue damage.

B. Wrapping the ankle in an Ace bandage can provide compression and support, which may help reduce swelling and stabilize the joint during the healing process. However, it's important not to wrap the bandage too tightly, as this can impair circulation.

C. Elevating the leg when sitting helps reduce swelling by promoting venous return and preventing fluid accumulation in the injured area. Keeping the ankle elevated above the level of the heart whenever possible is recommended for optimal swelling reduction.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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