The practical nurse (PN) assesses a child in 90-90 skeletal traction. It is most important for the PN to assess for signs of inflammation at which location?
A
B
C
D
The Correct Answer is A
A. Based on the understanding of 90-90 skeletal traction and the common complications associated with pin sites, the practical nurse should focus on assessing the areas around the pin insertion sites in the femur and possibly the tibia for any signs of inflammation.
B. the back is not the correct location
C. The sole of the foot is not the correct location
D. The unaffected limb is not the appropriate location.
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Related Questions
Correct Answer is B
Explanation
A. Turning on the infant warmer is a necessary step but comes after confirming that the infant is actually being born. The immediate priority is to assess the situation to ensure the health and safety of both the mother and baby.
B. Pushing the call light alerts other healthcare professionals that immediate assistance is needed. Given that the baby is crying, it suggests that the birth may have occurred unexpectedly, and help is required to manage the situation safely.
C. Notifying a healthcare provider is essential, but the PN should first verify the situation to provide accurate information and context for the healthcare provider's arrival.
D. Inspecting the perineum is important to assess for any complications or to check if delivery has occurred. However, this action should follow ensuring that help is called and that the environment is safe for both mother and baby. The primary focus should be on ensuring that assistance is on the way before performing an assessment.
Correct Answer is A
Explanation
A. A client who needs to ambulate for the first time since delivery requires the PN’s immediate attention to ensure safety and prevent complications such as orthostatic hypotension or falls.
B. A client prepared for discharge who has a question about teaching is important but does not take precedence over immediate safety concerns related to the client’s physical activity.
C. A tired client with twins who would like her babies returned to the nursery is important for the client’s well-being, but it is not as urgent as ensuring the safety of a postpartum client beginning to ambulate.
D. Removing indwelling urinary and intravenous catheters is important but not as urgent as ensuring the safety of a client ambulating for the first time after birth.
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