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NurseDive Free Nursing Practice Question
A nurse is assessing a child who has multiple closed fractures of the lower extremities due to a motor vehicle crash. The nurse should monitor the child for which of the following complications during the first 24 hr after the injury occurred?
A. Renal calculi
Renal calculi (kidney stones) are not directly related to fractures of the lowerextremities. They form in the kidneys and can cause pain and other symptoms when they pass into the urinary tract.
B. Osteomyelitis
Osteomyelitis is a bone infection that can occur as a complication of fractures, but it typically develops over a longer period of time than the first 24 hours after the injury.
C. Compartment syndrome
This is the correct answer. Compartment syndrome is a serious complication of fractures that can occur within the first 24 hours after injury. It is characterized byincreased pressure within a muscle compartment, leading to reduced blood flow, nerve compression, and tissue damage.
D. Volkmann ischemic contracture
Volkmann ischemic contracture is a complication that can occur if there is prolonged or severe muscle ischemia (lack of blood flow) following a fracture. It is not typically a concern within the first 24 hours after the injury
This question is an excerpt from Nurse Dive's nursing test bank - RN Nursing Care of Children 2019 with NGN Proctored Exam. Take the full exam now
Full Explanation
A. Renal calculi (kidney stones) are not directly related to fractures of the lower
extremities. They form in the kidneys and can cause pain and other symptoms when they pass into the urinary tract.
B. Osteomyelitis is a bone infection that can occur as a complication of fractures, but it typically develops over a longer period of time than the first 24 hours after the injury.
C. This is the correct answer. Compartment syndrome is a serious complication of fractures that can occur within the first 24 hours after injury. It is characterized by
increased pressure within a muscle compartment, leading to reduced blood flow, nerve compression, and tissue damage.
D. Volkmann ischemic contracture is a complication that can occur if there is prolonged or severe muscle ischemia (lack of blood flow) following a fracture. It is not typically a concern within the first 24 hours after the injury
Similar Questions
A nurse is caring for a child who has bacterial meningitis. Which of the following findings should indicate to the nurse that the child can be removed from droplet precautions?
A. Absent nuchal rigidity
Absent nuchal rigidity is a positive sign in the context of managing bacterialmeningitis, but it alone does not determine when droplet precautions can be discontinued.
B. Negative cerebrospinal fluid culture
This is the correct answer. A negative cerebrospinal fluid (CSF) culture indicates that the bacterial infection has been effectively treated. Once the CSF culture is negative, the child is no longer considered contagious and can be removed from droplet precautions.
C. Antibiotics initiated 24 hr ago
The initiation of antibiotics is an important step in treating bacterial meningitis, but the passage of time alone does not indicate when precautions can be discontinued. Theeffectiveness of treatment is better determined by laboratory and clinical indicators.
D. Temperature below 37.4° C (99.3° F)
The temperature is an important clinical parameter, but a temperature below 37.4° C (99.3° F) alone does not determine when droplet precautions can be discontinued. The decision is based on the resolution of the infectious process, as indicated by negative cultures.
Full Explanation
A. Absent nuchal rigidity is a positive sign in the context of managing bacterial
meningitis, but it alone does not determine when droplet precautions can be discontinued.
B. This is the correct answer. A negative cerebrospinal fluid (CSF) culture indicates that the bacterial infection has been effectively treated. Once the CSF culture is negative, the child is no longer considered contagious and can be removed from droplet precautions.
C. The initiation of antibiotics is an important step in treating bacterial meningitis, but the passage of time alone does not indicate when precautions can be discontinued. The
effectiveness of treatment is better determined by laboratory and clinical indicators.
D. The temperature is an important clinical parameter, but a temperature below 37.4° C (99.3° F) alone does not determine when droplet precautions can be discontinued. The decision is based on the resolution of the infectious process, as indicated by negative cultures.
A nurse is preparing to administer immunizations to a 3-month-old infant. Which of the following is an appropriate action for the nurse to take to deliver atraumatic care?
A. Provide a pacifier coated with an oral sucrose solution prior to the injections.
This is the correct action. Offering a pacifier coated with an oral sucrose solution before the injections can provide comfort and help alleviate pain associated with the immunizations.
B. Inject the immunizations into the deltoid muscle.
Administering immunizations into the deltoid muscle is not recommended for infants.For young infants, immunizations are typically given in the anterolateral thigh muscle.
C. Use a 20-gauge needle for the injections.
Using a 20-gauge needle is not recommended for infants, as it is a larger gauge and may cause more discomfort. A smaller gauge needle is typically used for infantimmunizations.
D. Apply eutectic mixture of local anesthetics (EMLA) cream immediately before the injections.
Applying eutectic mixture of local anesthetics (EMLA) cream immediately before the injections is not a standard practice for routine infant immunizations. It may not be necessary for most infants and could increase the overall time and complexity of the procedure.
Full Explanation
A. This is the correct action. Offering a pacifier coated with an oral sucrose solution before the injections can provide comfort and help alleviate pain associated with the immunizations.
B. Administering immunizations into the deltoid muscle is not recommended for infants.
For young infants, immunizations are typically given in the anterolateral thigh muscle.
C. Using a 20-gauge needle is not recommended for infants, as it is a larger gauge and may cause more discomfort. A smaller gauge needle is typically used for infant
immunizations.
D. Applying an eutectic mixture of local anesthetics (EMLA) cream immediately before the injections is not a standard practice for routine infant immunizations. It may not be necessary for most infants and could increase the overall time and complexity of the procedure.
A nurse is prioritizing care for four clients. Which of the following clients should the nurse assess first?
A. An adolescent who is in skin traction and reports a pain level of 7 on a scale from 0 to 10
An adolescent in skin traction reporting a pain level of 7 requires attention, but it is not as immediately concerning as the potential neurological symptom described in option B.
B. An adolescent who has sickle cell anemia and slurred speech
This client should be assessed first. Slurred speech in an adolescent with sickle cell anemia is a potential sign of a cerebral event, such as a stroke or a transient ischemic attack (TIA), and requires immediate evaluation.
C. A toddler who has a new diagnosis of osteomyelitis and is to receive an IV bolus of nafcillin
The toddler with a new diagnosis of osteomyelitis requiring an IV bolus of nafcillin should be assessed promptly, but this is not as urgent as the potential neurological symptom described in option B.
D. A toddler who has a partial-thickness burn on his right hand and requires a dressing change
The toddler with a partial-thickness burn on the right hand requiring a dressing change also requires attention, but it is not as immediately concerning as the potential neurological symptom described in option B.
Full Explanation
A. An adolescent in skin traction reporting a pain level of 7 requires attention, but it is not as immediately concerning as the potential neurological symptom described in option B.
B. This client should be assessed first. Slurred speech in an adolescent with sickle cell anemia is a potential sign of a cerebral event, such as a stroke or a transient ischemic attack (TIA), and requires immediate evaluation.
C. The toddler with a new diagnosis of osteomyelitis requiring an IV bolus of nafcillin should be assessed promptly, but this is not as urgent as the potential neurological symptom described in option B.
D. The toddler with a partial-thickness burn on the right hand requiring a dressing change also requires attention, but it is not as immediately concerning as the potential neurological symptom described in option B.