When caring for a child in balanced suspension skeletal traction using a Thomas splint and Pearson attachment to the right femur, which intervention is most important for the nurse to implement?
Monitor peripheral pulses and sensation in the right leg
Cleanse pin sites as prescribed
Check skin for redness and signs of tissue breakdown
Reposition the child every 2 hours
The Correct Answer is A
Choice A rationale
When caring for a child in balanced suspension skeletal traction using a Thomas splint and Pearson attachment to the right femur, the most important intervention for the nurse to implement is monitoring peripheral pulses and sensation in the right leg. This is crucial because the traction places tension on the bones, which can result in nerve or vascular damage. Changes in peripheral pulses and sensation can indicate potential complications, such as compromised blood flow or nerve compression, which need immediate attention to prevent further damage.
Choice B rationale
While cleansing pin sites as prescribed is important for infection prevention, it is not the most critical intervention in the context of assessing vascular and neurologic status.
Choice C rationale
Assessing skin for redness and signs of tissue breakdown is important for skin care and preventing pressure ulcers, but it is secondary to monitoring peripheral pulses and sensations when the child is in traction.
Choice D rationale
Changing position every 2 hours is a standard nursing practice to prevent pressure ulcers and provide comfort, but it does not take precedence over monitoring circulation and sensation in the affected limb.
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Related Questions
Correct Answer is A
Explanation
Choice A rationale
When caring for a child in balanced suspension skeletal traction using a Thomas splint and Pearson attachment to the right femur, the most important intervention for the nurse to implement is monitoring peripheral pulses and sensation in the right leg. This is crucial because the traction places tension on the bones, which can result in nerve or vascular damage. Changes in peripheral pulses and sensation can indicate potential complications, such as compromised blood flow or nerve compression, which need immediate attention to prevent further damage.
Choice B rationale
While cleansing pin sites as prescribed is important for infection prevention, it is not the most critical intervention in the context of assessing vascular and neurologic status.
Choice C rationale
Assessing skin for redness and signs of tissue breakdown is important for skin care and preventing pressure ulcers, but it is secondary to monitoring peripheral pulses and sensations when the child is in traction.
Choice D rationale
Changing position every 2 hours is a standard nursing practice to prevent pressure ulcers and provide comfort, but it does not take precedence over monitoring circulation and sensation in the affected limb.
Correct Answer is B
Explanation
Choice A rationale
Seeing spots is not a typical symptom of low blood sugar (hypoglycemia), which is a common concern for individuals with Type 1 diabetes. Seeing spots could be related to other health issues, such as eye conditions or neurological problems.
Choice B rationale
Profuse perspiration is a common symptom of hypoglycemia. When blood sugar levels drop, the body produces excess adrenaline, leading to sweating. Consuming a source of sugar would help to raise blood sugar levels and alleviate this symptom.
Choice C rationale
A racing pulse is not a specific symptom of hypoglycemia. It could be related to various conditions, including anxiety, dehydration, or heart conditions.
Choice D rationale
Excessive thirst is typically a symptom of high blood sugar (hyperglycemia), not low blood sugar. Consuming sugar when blood sugar levels are already high could potentially worsen the condition.
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