A nurse is caring for a child who had an open reduction and internal fixation (ORIF)of a femur fracture 12 hours ago.The nurse finds the child pale and short of breath.What action by the nurse takes priority?
A) Assess oxygen saturation while a coworker calls the physician.
B) Assess and treat the child for pain or anxiety as needed.
C) Raise the head of the bed to a 45°angle and reassess.
D) Review the child's postoperative hemoglobin and hematocrit.

Question

Quizplus · Accepted Answer

This child appears to be experiencing a complication of fracture,which may include shock,fat embolism,deep vein thrombosis,pulmonary embolism,and infection.Shortness of breath should alert the nurse to a respiratory complication as a first priority.The nurse should have a coworker call the physician while obtaining other assessment data,including oxygen saturation,vital signs,and a respiratory assessment.Although it is possible that a postoperative hemoglobin and hematocrit are low enough that the child is experiencing shock,the priority steps in assessing and intervening are airway,breathing,and circulation (ABCs),so breathing comes before circulation.The child may have pain or anxiety,but these are not the priority.Raising the head of the bed may or may not be helpful,but the nurse first needs to assess oxygen saturation.

A Nurse Is Caring for a Child Who Had an Open