When providing care for a child who is 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?
Cleanse pin sites as prescribed.
Monitor peripheral pulses and sensation in the right leg.
Assess skin for redness and signs of tissue breakdown.
Change position every 2 hours.
The Correct Answer is B
A. Cleansing pin sites as prescribed is important for infection prevention, but it is not the most critical intervention in the context of assessing vascular and neurologic status.
B. Monitor peripheral pulses and sensation in the right leg.
Balanced suspension skeletal traction is used to stabilize fractures or treat certain orthopedic conditions. Monitoring peripheral pulses and sensation in the right leg is a critical aspect of caring for a child in this type of traction. It is essential to ensure that the child's circulation and nerve function are not compromised. 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.
C. 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 sensation when the child is in traction.
D. 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.
Peripheral pulses and sensation must be closely monitored and documented at regular intervals to ensure the child's safety and the effectiveness of the traction. Any changes in these parameters should be promptly reported to the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","F"]
Explanation
In post-discharge care education for a 3-year-old with a history of ventricular septal defect, the nurse should include the following:
C. Alert the physician if the site bleeds or swells: This is important because it may indicate complications or issues related to the ventricular septal defect.
F. Monitor for fever: Fever can be a sign of infection or other concerns, so it's important to monitor for any changes in the child's temperature.
The other options are not applicable or advisable for post-discharge care in this context:
A. Keeping a pressure dressing on the site for one week is not typically necessary for ventricular septal defect and may not be appropriate for a 3-year-old.
B. Giving ibuprofen for pain is not relevant in this context, as pain management for ventricular septal defect is not typically managed with ibuprofen.
D. Giving only clear liquids for several days is not indicated for ventricular septal defect or post-discharge care.
E. Avoiding any kind of bath or shower is not a standard practice for post-discharge care for a child with a ventricular septal defect.
The focus should be on monitoring for signs of complications, such as bleeding, swelling, or fever, and seeking medical attention when necessary.
Correct Answer is D
Explanation
A. Giving the injection in the arm, one to 2 inches below the acromion process, is a technique typically used for adults or older children. It may not be suitable for a toddler of this age.
B. Using a needle length of 1/2 inch is not appropriate for intramuscular injections in a toddler. It may not reach the muscle tissue, leading to ineffective administration.
C. Dividing the gluteal area into quarters and giving the injection into the upper outer quadrant is a technique typically used for older children and adults, not for toddlers. It's also important to avoid intramuscular injections in the gluteal area for young children due to the risk of injury to the sciatic nerve.
D. Administering the injection into the middle of the lateral aspect of the thigh is the preferred technique for intramuscular injections in toddlers. The thigh muscles are a safe and effective site for IM injections in this age group. The middle of the lateral aspect of the thigh is commonly chosen because it provides a sufficient muscle mass for proper absorption of the medication and minimizes the risk of injury to nerves or vessels. This technique is recommended for toddlers who are walking and have developed sufficient muscle mass in the thigh area.
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