HESI Compound Fracture
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 nursing action has the highest priority?
assess the appearance of Cora's foot.
Which snack selection is the best choice for Cora while she is immobilized
pudding
In teaching the mother, what response should the nurse suggest she use with Cora
I am sad that you are throwing things at me
Which change in serum lab values would most likely indicate the onset of osteomyelitis?
Increased erythrocyte sedimentation rate (ESR)
Implementation of which nursing intervention will reduce this risk?
Initiate hourly assessment of Cora's foot distal to the fracture site
Which task should be delegated to the LPN at this time
Spend time with Cora to distract her from the discomfort
How should the nurse respond to this situation?
Support the mother's decision to hold Cora accountable for her own misbehavior
For which problem should Cora's parents be instructed to contact the health care provider?
Warm spots are felt on the cast
What volume of medication should the nurse administer?
0.3 ml
Which traction is a type of skeletal traction
90-90 Femoral
What action should the nurse take?
Acknowledge that the parents have correctly learned how to move the cast while wet
What action should the nurse implement?
Administer another dose of morphine immediately
When an older child is sitting on a booster seat, where is the best place to locate the seat?
Back seat of a car with lap and shoulder belts
What feature identifies Cora's fracture as an open fracture?
Bone fragments protruding through the skin
If unable to reach Cora's Parents, 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
Which nursing intervention should be included in the plan of care while Cora is in traction?
Ensure that the amount of weight remains consistent
What action should the nurse take?
Give Cora a few crackers and stay with her while she eats them
How should the nurse respond?
Instruct this parent that the child's age and size still require the use of a safety seat
What is the best response by the nurse?
It is natural to be upset when your child expresses anger toward you
3. How is the presence of crepitus related to this femur fracture determined?
Listen for grating sound when the affected area is moved
In addition to notifying the healthcare provider of this development, what action should the nurse implement?
Obtain equiptment needed for cast removal
Given the available nursing pesonnel, what staff assignment is best?
Ongoing monitoring of Cora's foot by the LPN, while the UAP assists the postoperative client with crutches, and the RN determines if the new client has any immediate problems
Which activity is the best choice for Cora?
Pretend beauty palor
Since Cora's parents whose are divorced, which parent should the nurse try to contact first?
The parent who has been assigned legal custody of Cora by the court
What additional assessment should the nurse perform?
Toe movement