When providing care 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?

Change position every 2 hours.

Monitor peripheral pulses and sensation in the right leg.

Cleanse pin sites as prescribed.

Assess skin for redness and signs of tissue breakdown.

Answer and Explanation

The Correct Answer is B

When caring for a child in balanced suspension skeletal traction, the most important intervention for the nurse to implement is monitoring peripheral pulses and sensation in the aﬀected leg to detect any compromise in circulation or nerve function. This is crucial because the traction places tension on the bones, which can result in nerve or vascular damage.

Changing positions every 2 hours is important to prevent pressure injuries, but it is not the most critical intervention.

Cleansing pin sites and assessing skin for redness and signs of tissue breakdown are also important, but they are not as urgent as monitoring peripheral pulses and sensation.

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Correct Answer is A

Explanation

The nurse should inspect the posterior oropharynx of a child who is frequently swallowing after tonsillectomy to assess for bleeding or the presence of clots. Swallowing frequently can be a sign of postoperative bleeding, which is a potential complication of tonsillectomy.

Touching the tonsillar pillars to stimulate the gag reﬂex or asking the child to speak would not provide information about the presence of bleeding.

Assessing for teeth clenching or grinding is not related to this particular observation.

A. White blood cell count of 10,000/mm (10x 10/L). B. Weight gain of 2 pounds (0.91 kg) since birth. C. Red blood cell count of 2.3 cell/mcl or (2.3 x 10/L). D. Urine specific gravity is 1.011.

Correct Answer is C

Explanation

Answer: C. Red blood cell count of 2.3 cells/mcl or (2.3 x 10/L).

Rationale:

A. White blood cell count of 10,000/mm³ (10 x 10⁹/L): This is within the normal range for an infant, indicating no immediate concern for infection or immune response. It does not need to be urgently conveyed to the surgeon.

B. Weight gain of 2 pounds (0.91 kg) since birth: This is a positive sign indicating healthy growth and nutritional status, but it is not a critical concern that would affect the immediate surgical plan.

C. Red blood cell count of 2.3 cells/mcl or (2.3 x 10⁹/L): This low RBC count indicates anemia, which is critical information for the surgeon. Anemia can increase the risk of complications during and after surgery due to potential issues with oxygenation and healing, making it the most important information to convey.

D. Urine specific gravity is 1.011: This indicates normal hydration status and is not immediately relevant to the surgical procedure. It does not need to be urgently reported to the surgeon compared to the low RBC count.

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When providing care 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While obtaining the vital signs of a 10-year-old child who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to 3 minutes. Which assessment should the nurse implement?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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