A 4-year-old child is placed in Buck extension traction for Legg-Calvé-Perthes disease. He is crying with pain as the nurse assesses the skin of his right foot and sees that it is pale with an absence of pulse. What should the nurse do first?
a. Reposition the child and notify the practitioner.
b. Notify the practitioner of the changes noted.
c. Give the child medication to relieve the pain.
d. Chart the observations and check the extremity again in 15 minutes.
ANS: B
The absence of a pulse and change in color of the foot must be reported immediately for evaluation by the practitioner. This is an emergency condition. Pain medication should be given after the practitioner is notified. The findings should be documented with ongoing assessment.
You might also like to view...
A nurse assesses an older adult client who has multiple chronic diseases. The client's heart rate is 48 beats/min. Which action should the nurse take first?
a. Document the finding in the chart. b. Initiate external pacing. c. Assess the client's medications. d. Administer 1 mg of atropine.
The nurse is assessing the 1-month-old infant's fontanels. The infant's fontanels are sunken. What may this indicate to the nurse?
1. Infection 2. Thyroid disease 3. Dehydration 4. Fetal Alcohol Syndrome
Which of the following clients is most likely to experience difficulty returning to sleep?
1. A 60-year-old with benign hypertropic prostatic disease 2. A 15-year-old with type 1 diabetes 3. A 35-year-old diagnosed with hypothyroidism 4. A 55-year-old diagnosed with hypertension
A patient with depression infers that symptoms result from an imbalance of yin and yang. Select the best question to elicit information to guide nursing care that will accommodate the patient's culture
a. "Who should receive information about your health problems?" b. "Are you concerned about treatment in a hospital setting?" c. "Are you willing to take Western medications?" d. "What foods will help this problem?"