Difficulty: Medium
Average Score: 95%
Simulated
Passage / Scenario
5-year-old male 18 kg (39.7 lb) admitted following a motor-vehicle crash. Surgical procedure: L leg open reduction and fixation, L arm closed reduction and fixation. Vital Signs: Pulse rate 68/min, Respiratory rate 12/min, Blood pressure 80/42 mm Hg, Temperature 38.6° C (101.5° F), Oxygen saturation 91%. Medications: 0.9% sodium chloride IV at 100 mL/hr, Morphine 0.5 mg/hr IV, Acetaminophen 200 mg PO every 4 hr PRN for temperature >38° CA nurse is caring for a child who is 2 hr postoperative. Which of the following actions should the nurse take first?
Correct answer
A
Rationale
Step 1: Assess circulation first to ensure adequate blood flow and oxygen delivery to the extremities. Step 2: Compare the child's pedal pulses to establish baseline perfusion status. Step 3: This helps in early detection of any potential circulatory compromise. Step 4: If pulses are weak or absent, immediate intervention can be initiated to prevent further complications. Comparing pedal pulses is the priority as it directly assesses perfusion status. Other options like determining sedation level, assessing pain, or rechecking temperature can be addressed after ensuring adequate circulation.