WK 5 Fractures, Musculoskeletal congenital disorders

pressure ulcer

- pressure on soft tissue or boney prominence. - Notify HCP of hotspot or tightness under cast. Window Edema: swelling of tissue that bulges through the window of opening - TX: may need bivalve to inspect and treat ulcer.

Crutches

- uninjured leg first - always ensure rubber tips are on crutches and monitor if they are worn out/wet; dry them - arms bear weight of body not armpits; pressure to axillae can damage radial nerve=weakness and aprtial paralysis below elbow

Greenstick

incomplete fracture of the bone

s/s of compartment syndrome?

5 P's (pain, paresthesia, paralysis, pallor, pulselessness)

club foot - what is: talipes varus/valgus, talipes calcneus, talipes equines, talipes equinovarus - DX, TX,

- deformity of ankle/foot, can be biliteral or unilaterally~ assocaited with cerebral palsy and spinal bifida - expected findings: Talipes varus (inversion)/valgus (eversion), talipes calcneus (dorsiflexion, toe higher than heel), talipes equines ("horse foot" plantar flexion toes lower than the heel), tarlipes equinovarus (toes facing inward and tower than heel) - DX: US, visual inspected - TX: cereal casting over 4-6 weeks* then heel cord tenotomy after long leg cast for 3 weeks? after 6 weeks denis browne bar connects specialized shoe to prevent reocurrance - NC: do not miss apt, wear for 24hr day, change diaper frequently, assess neuro, 5 P's

PIN CARE

- elevate leg above heart to decrease swelling, monitor CMS - assess pins site for infection (osteomylelitis, increased drainage/redness/swelling, tenting at pins site) - aseptic/sterile technique, daily or weekly per order - monitor pins for loosening (Notify HCP, nurses cant adjust this!) - clean one pin at a time-use new cotton tip swab for each pin (guaze, cotton tip) with chlorhexidine2mg/mL - do not remove crusting this is a barrier to prevent bacteria from going in - document pin site appearance

what is halo traction for? what is a huge priority in case of life-threatening emergency?

- for spinal deformities - NC: monitor v/s q 4 hours, ALWAYS have wrench attached on halo vest in case of life-threatening emergency and move patient as one unit never add pressure to rods

Legg Perthe-Calve Disease

- necrosis of femoral head - s/s: painless limp; prolonged limping will cause surrounding joints to hurt - stages: synovitis, necrotic, fragmentation, reconstruction - encourage isotonic exercises (taichi) - TX: actiivty restriction, limited weight bearing, PT, NSAIDS, surgery (ostetomy)

principles of traction

- never lift or remove weights, let hang freely - never rest floor - muscle spasms are expected; nurse can admin muscle relaxants or analgesics/heat massage/repositioning if not successful notify HCP - ropes must be interrupted or touch floor, do not touch pulley or the foot of the bed - keep body neutral, sponge bath - might need incentive spirometer; to prevent acteletesis

body cast

- Body cast: immobilize spine / Spica cast: immobolize spine - Monitor for constipation d/t immbolized body, increase fiber and fluids.

What are some family teaching regarding the Pavlik Harness?

- DDH - Avoid lotions or powders - Should be worn 23 hours per day for about 6 weeks - Undershirt and socks under harness - Place diaper under the straps - Triple/double diapering is not recommended - Do not adjust harness. This is done by a provider in office every 1-2 weeks

bryant traction is used for?

- DDH in children - Legs are flexed at 90 degrees with buttocks raised slightly off the bed

Developmental Dysplasia of The Hip (DDH) - define types: acetabular dysplasia, sublaxation, dislocation - DDH S/S infant and child - TX for <6mo and >6mo - NC

- DDH: abnormal dev of the hip, can happen while in the uterus. - Acetabular dysplasia: delay in acetabular development (acetabular roof is shallow and oblique) - Subluxation: incomplete dislocation of the hip - Dislocation: femoral head does not have contact with the acetabulum - S/S infant: + ortolani/barlow, Leg length asymmetry, asymmetrical inguinal or gluteal skin folds, limited hip joint ROM, asymmetrical gait - S/S child: one leg shorter than other, walks with limp, walks on toes - TX <6mo: PAVLIK HARNESS, wear for 23hr/day, wear shirt under, meet w/ hcp q1-2 weeks to adjust; do not adjust, massage skin under strap to promote circulation - TX >6mo: closed reduction w/ hip spica cast, bryant traction (like hajeon) 90 degree angle buttocked raised off bed and on back - DDH Post complications: Post op- Atelectasis, ileus, infection Complications of immobilization: weakened muscle, bone demineralization, altered bowel motility. - Complications of casting: skin breakdown, neurovascular alterations. Infection can be caused by bacteria (staph) - PT EDU for the cast: position cast on pillow, keep elevated until dry, change position frequently to allow for drying, note color of palm and toes on cased extremity, sponge baths to avoid wetting cast, use appropriate equipment (stroller, wagon, car seat; accommodate large cast) for maintaining mobility

disuse syndrome

- DisUSE Syndrome: when you don't use muscles for a while they become weak and not work as well. - NC: Encourage ISOMETRIC exercises hourly when pt is awake (Tai chi, yoga)4)

S/S of Fracture "BROKEN"

B- Bruising over the site (discolored with swelling) and pain R -Reduced movement of extremity or muscle O - Odd appearance (looks abnormal) K - Krackling sounds due to bone fragments rubbing together (crepitus) E - Edema and erythema at the site N - Neurovascular impairment...5 P's (ischemia: pain, pallor, paralysis, paresthesia, pulselessness (late sign)

Oblique

Break is diagonal across the bone

Spiral

Break spirals around the bone* S/S of abuse

CASTS (fiber and plaster)

COMPLETELY IMMOBILIZE FRACTURE + SURROUNDING JOINTS. - fiberglass, need to work fast like 30 minutes to reach full rigidity because the mold hardens fast - plaster: more time to mold 24-72 hr to dry, use palm of hands to handle with NOT fingers* to prevent denting, risk for thermal injury, feeling a bit hot is normal bc chemical reaction

A nurse is caring for a client who has a fractured right hip. Which of the following types of traction should the nurse expect the client to have prior to hip arthroplasty surgery? ( A. Balanced skeletal traction B. Pelvic belt C. Pelvic sling D. Buck's traction Check Answer

Close Explanation Correct Answer: D. Buck's traction Buck's traction is used prior to hip arthroplasty to maintain alignment and prevent muscle spasms prior to surgery. Incorrect Answers: A. Balanced skeletal traction is used to stabilize fractures of the femur or pelvis, not the hip. Skeletal traction involves the surgical insertion of pins, tongs, wires, or screws; this is sometimes used to stabilize long bone and vertebral fractures. B. A pelvic belt is used to treat back pain and does not provide traction prior to hip arthroplasty. C. A pelvic sling is used to stabilize pelvic fractures, not hip fractures.

Closed/simple

Closed or simple: The fracture occurs without a break in the skin.

A nurse is providing teaching about home care to the parent of a child who has a newly applied fiberglass leg cast. Which of the following statements should the nurse include? A. "Monitor the color of your child's toes every 4 hours for 24 hours." B. "Your child can scratch the skin inside the cast with a small wooden ruler" C C. "Expect the cast to remain damp for 72 hours." D. "You can take your child swimming and give baths as usual."

Correct Answer: A. "Monitor the color of your child's toes every 4 hours for 24 hours." The nurse should instruct the parent to monitor the color of the child's toes every 4 hours to check for alterations in perfusion. The nurse should instruct the parent to notify the provider if the child's toes are discolored or cool to the touch. Incorrect Answers: B. The nurse should instruct the parent not to insert anything into the cast to avoid injury to the skin, which can cause infection. The parent should blow cool air into the cast with a hair dryer or fan if the child experiences itching. C. The nurse should instruct the parent that the fiberglass cast will dry within 30 minutes. Casts made from plaster take up to 72 hours to dry. D. The nurse should instruct the parent that the cast must stay dry at all times. The parent should cover the cast with a plastic bag before the child showers or bathes and assist the child as necessary to ensure the cast stays dry when bathing.

A nurse is providing teaching to an adolescent who has a fiberglass arm cast. Which of the following instructions should the nurse include in the teaching? A. Place a plastic bag over the cast when showering B. Insert a dull knitting needle into the cast to rub itchy skin C. Exercise fingers every & hr for the first 24 hr D. Draw on the cast using magic markers

Correct Answer: A. Place a plastic bag over the cast when showering The nurse should instruct the adolescent to keep the cast dry by placing a plastic bag over it while showering. Incorrect Answers: B. Placing any instruments inside the cast can injure the skin and cause an infection. C. The fingers should be moved and exercised every 4 hours for the first 24 hours. D. Fiberglass cast material is porous; therefore, magic markers should not be used to draw on or autograph the cast.

A nurse is assessing a client who is 48 hr postoperative following open reduction and internal fixation of a fractured tibia. Which the following findings should the nurse report to the provider? A. Toes that are cold to the touch B. Serous drainage from the pin sites c. Blanching of the toenail beds with pressure D. Pink tissue around the fixator insertion sites

Correct Answer: A. Toes that are cold to the touch The nurse should monitor for and report manifestations of compartment syndrome following internal fixation. Therefore, the nurse should contact the provider immediately if the client's toes are cold to the touch. Incorrect Answers: B. The nurse should identify serous drainage from the pin sites as an expected finding during the first 2 to 3 days following the procedure. C. As part of measuring capillary refill, the nurse should press the nail bed long enough to produce a blanching appearance. Therefore, the nurse does not need to report this finding. D. The nurse should identify pink to red tissue at the fixator insertion sites as an expected finding for the first 2 to 3 days following the procedure.

A nurse is caring for a child who has been in Buck's traction for 2 days. Which of the following actions should the nurse take to prevent complications? A. Manually move the weights to the floor when the child is experiencing pain B. Check for pulses in the affected leg every 4 hr C. Cleanse the pins every 12 hr D. Inform parents to discourage visitors for the child

Correct Answer: B. Check for pulses in the affected leg every 4 hr Traction might lead to neurovascular compromise. The nurse should assess for edema, pulses, pain, color, and temperature of the extremity every 4 hours. Incorrect Answers: A. The nurse should not move or adjust the weight to ensure proper alignment and correct healing. C. Buck's traction is skin traction, which works without the use of pins. D. A child who is in Buck's traction is not ill and should be encouraged to continue socialization through various means.

A nurse is caring for a client who has a fractured hip and was placed in Buck's traction 4 hr ago. Which of the following actions should the nurse take? A. Inspect the client's skin underneath the boot every 12 hr B. Encourage the client to perform dorsiflexion of the affected extremity every 2 hr C. Remove the weights from the traction while repositioning the client in bed D. Loosen the ropes if the client reports muscle spasms in the affected extremity

Correct Answer: B. Encourage the client to perform dorsiflexion of the affected extremity every 2 hr The nurse should encourage the client to perform dorsiflexion of the affected extremity every 2 hours to assess if the client is experiencing nerve damage. Weakness of dorsiflexion can indicate peroneal nerve damage. If this occurs, the nurse should notify the provider immediately. Incorrect Answers: A. The nurse should inspect the client's skin underneath the boot for irritation, increased swelling, and skin breakdown every 8 hours. C. The weights should never be removed without a prescription from the provider. The purpose of the weights is to decrease muscle spasms as a result of the hip fracture. D. The ropes of the traction should never be loosened. This can affect the traction and increase the client's muscle spasms.

A nurse is assessing a client who has a fractured left femur and is in skeletal traction. Which of the following findings should the nurse report to the provider? A. Ecchymosis of the thigh B. Serous drainage at the pin site C. Chest petechiae D. Muscle spasms in the left leg

Correct Answer: C. Chest petechiae The nurse should identify chest petechia as an indication of fat embolism syndrome. Clients who have fractures of the long bones such as the femur are at increased risk of fat emboli. Fat emboli typically occur 12 to 48 hours after the injury when fat droplets from the marrow enter into the systemic circulation and are deposited in the lungs. The nurse should immediately notify the provider because the client could progress to acute respiratory failure. Incorrect Answers: A. Ecchymosis of the thigh as an expected finding for a client who has a fractured left femur. B. Serous drainage is expected at the pin site for a client who is in skeletal traction. The nurse should monitor for purulent drainage that can indicate an infection at the site. D. Muscle spasms in the left leg are an expected finding for a client who has a fractured left femur.

A nurse is caring for a school-aged child who had an arm cast applied 8 hours ago. Which of the following findings should alert the nurse to a complication related to the casting? A. The child reports a pain level of 5 on a scale of O to 10 B. The child's hands are cool bilaterally C. The child reports tightness at the wrist D. The child's grasp is weak

Correct Answer: C. The child reports tightness at the wrist The nurse should monitor the casted extremity to ensure the swelling does not increase and cause the cast to become too tight, which can result in impaired circulation. If this occurs, the child is at risk for compartment syndrome. Incorrect Answers: A. The nurse should expect the child to have mild to moderate pain due to the fracture; therefore, a pain level of 5 on a scale of 0 to 10 is an expected finding. If the pain becomes severe and is unrelieved by analgesics, it could indicate an impairment in circulation. B. The nurse should monitor the child for indications of impaired circulation after a cast is applied. The nurse should be concerned if only the casted extremity is cool but not if the finding is bilateral. D. The nurse should expect the child to have impaired function such as a weak grasp due to the fracture. However, if the child develops paralysis of the extremity, it could indicate an impairment in circulation.

A nurse on a medical-surgical unit is planning the care of assigned clients. Which of the following clients should the nurse attend to first? A. A client who is newly admitted and is scheduled for indwelling urinary catheter insertion B. A client who has kidney stones and reports flank pain of 6 on a pain scale of 0-10 C. A client diagnosed with early stage chronic kidney disease with a serum creatinine level of 2.0 mg/dL D. A client who has a cast newly applied on the forearm and reports tingling of the fingers

Correct Answer: D. A client who has a cast newly applied on the forearm and reports tingling of the fingers When using the airway, breathing, circulation (ABC) approach to client care, the nurse should first assess the client who has a newly applied cast on the forearm and reports tingling of the fingers. Tingling, numbness, pallor, paresthesia, and pain are clinical manifestations associated with compartment syndrome, a serious development in which increased tissue pressure in a confined anatomical space reduces blood flow, leading to ischemia, dysfunction, and eventual necrosis. The nurse should report this finding to the provider immediately. Incorrect Answers: A. The nurse should assess a client who is newly admitted and is scheduled to have an indwelling urinary catheter to empty the bladder of urine; however, there is another client the nurse should attend to first. B. The nurse should assess a client who has kidney stones and reports a flank pain of 6 on a pain scale of 0-10 to address and treat the client's pain; however, there is another client the nurse should attend to first. C. The nurse should assess a client diagnosed early with early stage chronic kidney disease who has a serum creatinine of 2.0 mg/dL to determine kidney function; however, there is another client the nurse should attend to first.

A nurse is caring for a 7-year-old child who is in skeletal traction following a complete fracture of the femur. Which of the following diversional activities should the nurse offer the child? A. Puzzle with large pieces O B. Building blocks ( C. Finger paints D. Chapter books

Correct Answer: D. Chapter books The nurse should offer chapter books as an appropriate diversional activity for a school- age child who has limited movement due to skeletal traction. Incorrect Answers: A. The nurse should offer a puzzle with large pieces as a diversional activity for a preschooler. B. The nurse should offer building blocks as a diversional activity for a preschooler. C. Although school-age children enjoy crafts such as painting, finger painting is a diversional activity the nurse should offer a toddler.

A nurse is caring for a school-age child who has skeletal traction applied to repair a pelvic fracture. Which of the following actions should the nurse take? A. Rest the child's traction weights on the floor for 8 hr during the night O B. Ensure the child's meal tray contains no high-fiber foods C. Perform passive range-of-motion exercises on the child's involved joints every 4 hr D. Place the child on a pressure-reduction mattress

Correct Answer: D. Place the child on a pressure-reduction mattress Placing the child on a pressure-reduction mattress will alleviate the pressure on bony prominences, which decreases the risk of skin breakdown. Incorrect Answers: A. The nurse should not release or lift the weights that are applying the traction for any reason. If an issue should arise in which the weights require adjustment, the nurse should contact the provider or the physical therapist, depending on facility policy. B. The immobility associated with traction causes constipation. Therefore, the nurse should promote the intake of a high-fiber diet and ensure the child's meal tray contains as many high-fiber foods as the child will consume. C. The body should be maintained in correct alignment, and the joints should be kept at the angles set by the provider and the physical therapist, depending on the child's

A nurse is caring for a client with a hip fracture who has Buck's extension traction in place. Which of the following pieces of information should the nurse give the client about this type of traction? (Select all that apply.) A. "You'll have considerably less pain with the traction in place." B. "You'll have the traction in place for a week or so." C. "The traction will help decrease muscle spasms." D. "The weights act as a pulling force to keep your leg and hip still." E. "We have to make sure the weights are just barely touching the floor."

Correct Answers: A. "You'll have considerably less pain with the traction in place." C. "The traction will help decrease muscle spasms." D. "The weights act as a pulling force to keep your leg and hip still." Pain is usually more severe without the traction. Buck's extension traction uses weights to help decrease muscle spasms. Typically, 2.3 to 5.5 kg (5 to 10 lb) of force helps stabilize the hip and leg preoperatively. Incorrect Answers: B. Buck's extension traction is for short-term stabilization of a hip fracture prior to surgery. E. The weights must stay suspended at all times and should not touch the floor.

In a client who is using weights for traction, what is the most important thing to remember?

Do not lift/remove weights and do not let the weights rest on the floor. They should always be hanging freely!

Physeal (growth plate)

Injury to the end of the long bone on the growth plate

Open/compound

Open or compound: The fracture occurs with an open wound and bone protruding.

SPLINTS

Simple fractures

Plastic deformation (bend)

bone is bent 45' without breaking

Transverse

break is straight across the bone

skeletal traction

for long bone fractures

S/S of casts to report

hotspot, malodor, increased pain, cool digits, change in skin color, tightness under cast (common with pressure ulcer)

Stress

small fracture/cracks in the bone due to repeated contractions during weight-bearing

BRACE

support and control movement

Osteogenesis Imperfecta - expected findings - meds and what to monitor for - pt edu

- brittle bones d/t lack of collagen, not calcium issue - expected findings: multiple bone fractures (rule out abuse), blue sclera*, early hearing loss, small disclored teeth, small stature - med: class: bisphosphonate pamidronate IV to help strengthen bone and decrease fracturs. Monitor for adverse effects (hypoca+/k+/mg+, thrombocytopenia, neutropenia, dysrhythmia, kidney failure, general malaise), monitor for respiratory infection, may require assistive devices (crutches-unaffected leg first, wheel chair) - pt edu: NO live vaccine, ABX prophylax before dental work, low impact exercises

casts, splint, braces nursing care

- remove jewelry, immobilize affected joints. - elevate above heart first 48 to prevent swelling - assess CMS and 5 P's Q1 hr for 24 hr then 1-4 hr - do not place anything in cast but can use cool air to relieve itching - discharge pt edu: notify hcp if increasing in pain/hotspots/malodor/increased drainage

Skin traction (bucks)

- short-term treatment (48-72 hours) and is applied directly to skin; used until skeletal traction or surgery is available to treat fracture - helps reduce of a fracture (does not primarily achieve reduction) and helps decrease muscle spasms - ambulate patient to prevent pressure ulcers, LOG ROLL* Weights range from 2.3 to 4.5 kg (5 to 10 lb)

SCOLIOSIS

- Expected findings: laterally curvature, asymmetry of scapula/ribs/flanks/shoulders/hips, one leg shorter than the other. IMPROPERLY FITTING CLOTHING* - DX: sAdam's bend test: have the child the child bend over at waist with arms hanging down to observe for asymmetry of ribs and flanka and measure curvature with scoliometer , screen preadolescent (age __ __), Cobb technique to determine degree of curvature. Risser scale for skeletal maturity. MRI CT - TX: braces (TSLO, WIlmington, Charleston, Boston) wear for 23hr/day, for curvature >45 spinal fusion w/rod - Complications: spine/nerve dmg, difficulty breathing, low self-esteem (help w age-appropriate activities to promote self esteem), small bowel obstruction, infection (staph bacteria)

compartment syndrome

- Increased pressure, which causes impaired circulation. - S/S: pain that doesnt go away with meds, 5 P's (pallor, pain, paresthesia, pulselessness), *HALLMARK S/S: intensified pain w/ PROM delayed cap refill, dusky, pale, cool skin - TX: Loosen or cast bivalve (cut the cast and gap for space) no relief —> Fasciotomy to ease the pressure (invasive)

In a client with halo traction, what is a priority to remember?

- Make sure wrench/screwdriver are attached to the vest to release patient from device in case of an emergency - Move patient as a unit and do not apply pressure to the rods

cervical traction

- applied as a treatment for an injured neck (regina g)

Comminuted

Comminuted: The fracture includes tiny fragments of bone that lie in the surrounding tissue.

Complete, Incomplete

Complete: Bone fragments are separated. Incomplete: Bone fragments are still attached.

Complicated fracture

Complicated fracture: The fracture injures other organs and tissues.

Buckle (torus)

Compression of the porous bone resulting in a bulge or raised area at the fracture site

A nurse is caring for a client who is in skeletal traction following a femur fracture. On entering, the nurse finds that the client has slid toward the foot of the bed, and the traction weight is resting on the floor. Which of the following actions should the nurse take? A. Remove the weight temporarily to reposition the client to the correct alignment in bed B. Have the client use a trapeze to pull himself up while ensuring the weight hangs freely c. Lift the rope off the pulley while the client rocks back and forth to reposition himself D. Lift the weight manually while another staff member moves the client up in bed

Correct Answer: B. Have the client use a trapeze to pull himself up while ensuring the weight hangs freely The nurse should ensure that traction weight is hanging freely. The client can use an overhead trapeze bar to move up in bed, or the nurse can assist the client while making sure to maintain proper alignment of the extremity. Incorrect Answers: A. The nurse should not remove the weight without a prescription, as this could interfere with the correct alignment of the extremity. C. The nurse should ensure the traction ropes are on the pulley. Lifting the rope displaces the weight and can interfere with the correct alignment of the extremity. D. The nurse should not lift the weight without a prescription because this could interfere with the correct alignment of the extremity.

A nurse is assessing an adolescent who has sustained a broken tibia. Following the application of a fiberglass cast, the adolescent reports pain and a tingling feeling in the limb. Which of the following actions should the nurse take first? A. Give the adolescent ibuprofen B. Elevate the adolescent's leg on pillows c. Place an ice pack on the cast D. Assess for manifestations of circulatory impairment

Correct Answer: D. Assess for manifestations of circulatory impairment The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be open for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the nurse should first assess for circulatory impairment to ensure there is no vascular compromise. Incorrect Answers: A. The nurse should give the adolescent ibuprofen to manage pain; however, there is another action the nurse should take first. B. The nurse should elevate the adolescent's leg on pillows to prevent edema; however, there is another action the nurse should take first. C. The nurse might give the adolescent an ice pack to help with pain; however, there is another action the nurse should take first.

A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. On assessment, the nurse notes that the client's wound has eviscerated. Which of the following actions should the nurse take? (Select all that apply.) A. Carefully reinsert the intestine through the opening in the wound B. Place the client in a supine position with the hips and knees flexed C. Leave the room to call the surgeon D. Cover the wound and intestine with a sterile, moistened dressing E. Monitor the client for manifestations of shock

Correct Answers: B. Place the client in a supine position with the hips and knees flexed D. Cover the wound and intestine with a sterile, moistened dressing E. Monitor the client for manifestations of shock The nurse should place the client in a supine position with the hips and knees flexed. This position can help to prevent further tearing of the incision and wound evisceration by lessening tension on the wound. The nurse should cover the protruding intestine with a sterile dressing that is moistened with 0.9% sodium chloride to prevent further contamination of the wound and to keep the protruding intestine from drying out. The nurse should monitor the client for a physiological stimulus (e.g. bleeding from the tearing or opening of the wound) or a psychological stimulus (e.g. viewing the intestine protruding outside of the body), which can increase the risk of shock. The nurse should monitor the client for increased heart rate and respiratory rate, changes in blood pressure or mentation, and cool or clammy skin. Incorrect Answers: A. The nurse should not attempt to reinsert the intestine into the client's abdominal cavity because this action can cause perforation of the intestine. The nurse should plan to transfer the client to surgery, where the surgeon will reinsert the intestine under sterile technique. C. The nurse should delegate another person to notify the surgeon immediately. The nurse should stay with the client and observe for further complications such as shock.

A nurse is caring for a child who is in skeletal traction. Which of the following actions is the nurse's priority? A. Perform passive range of motion for unaffected joints B. Massage the child's pressure areas C. Increase the child's fluid intake D. Encourage the child to use an incentive spirometer

D. Encourage the child to use an incentive spirometer The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Encouraging the child to use an incentive spirometer will promote adequate oxygenation and is the priority nursing action. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Incorrect Answers: A. The nurse should perform passive range of motion for unaffected joints; however, a different action is the nurse's priority. B. The nurse should massage the child's pressure areas; however, a different action is the nurse's priority. C. The nurse should increase the child's fluid intake; however, a different action is the nurse's priority.