HESI Case Study: Compound Fracture (Preschooler)-Madison

As the nurse assumes care for the client, which actions are most important for the nurse to take? (select all that apply)

-stabilize the injury -assess neurovascular status every hour -place an ice pack over the injury -elevate the affected extremity

Madison weighs 33lbs, and the prescribed dose is 0.2mL/kg and the vial is labeled 5mg/mL. How many mL of medication should the nurse administer?

0.6mL

Given the available medical personnel, what staff assignment is best?

ongoing monitoring of Madison's foot by the LPN, while the UAP assists the postoperative client with crutches and the nurse determines if the new client has any immediate problems

Which snack selection is the best choice for Madison while she is immobilized?

pudding

Which task should be delegated to the LPN at this time?

spend time with Madison to distract her from the discomfort

How should the nurse respond to this situation?

support the mother's decision to hold Madison accountable for her own misbehavior

What additional assessment should the nurse perform?

toe movement

In teaching the mother, what response should the nurse suggest she use with Madison?

"I am sad that you are throwing things at me."

What is the best response by the nurse?

"It is natural to be upset when your child expresses anger toward you."

Which traction is a type of skeletal traction?

90-90 Femoral

What action should the nurse take?

give Madison a few crackers and stay with her while she eats them

What feature identifies Madison's fracture as an open fracture?

Bone fragments protruding through the skin.

Which activity is the best choice for Madison?

Pretend beauty parlor

Which nursing interventions should be included in the plan of care while Madison is in traction?

-assess toes for capillary refill and edema -ensure that the amount of weight remain consistent

The nurse understand that which signs and symptoms are indicative of the osteomyelitis complication? (select all that apply)

-pain that increases with movement -edema -irritability

The nurse explains to Madison and her parents that which will occur during and after the cast is removed? (select all that apply)

-she may feel heat or a vibration or a tickle during the removal -the machine to remove the cast is very noisy -skin might be scaly or dry after the cast is removed

If a staff member is unable to reach Madison's parent, what guidelines will determine the staff's ability to provide needed care?

Emergency care may be provided after a reasonable attempt to reach the parents has been made.

Implementation of which nursing intervention will reduce the risk?

Initiate hourly assessment of Madison's foot distal to the fracture site.

How is the presence of crepitus related to this femur fracture determined?

Listen for a grating sound when the affected area is moved

Since Madison's parents are divorced, which parent should the nurse try to contact first?

The parent who has been assigned legal custody of Madison by the court.

What action should the nurse take in response to how they are handling the care of the cast?

acknowledge that the parents have correctly learned how to move the cast while it is wet

What action should the nurse implement?

administer another dose of morphine immediately

Which nursing action has the highest priority?

assess the appearance of Madison's foot

When an older child is sitting on a booster seat, where is the best place to locate the seat?

back seat of the car with lap and shoulder belts.

Which nursing intervention should be included in the plan of care to prevent this complication?

cleanse around the pin site with half-strength hydrogen peroxide

Which technique is most beneficial when preparing a preschooler for a procedure that may be frightening?

describe what the child will experience shortly before the procedure takes place

Which change in serum lab values would most likely indicate the onset of osteomyelitis?

increased erythrocyte sedimentation rate (ESR)

How should the nurse respond?

instruct this parent that the child's age and size still require the use of a safety seat

In addition to notifying the healthcare provider of this development, what action should the nurse implement?

obtain equipment needed for cast removal

For which problem should Madison's parents be instructed to contact the healthcare provider?

warm spots are felt on the cast