A nurse is caring for a school-age child who has a fracture to the right femur. Which of the following findings is the nurse’s priority?
2+ right pedal pulse
Tingling in the right foot
Capillary refill less than 2 seconds
Respiratory rate 24/min
The Correct Answer is B
Choice A rationale
A 2+ right pedal pulse indicates a normal pulse and is not a cause for immediate concern in a child with a femur fracture.
Choice B rationale
Tingling in the right foot could indicate nerve damage or compromised blood flow, which can be a serious complication of a femur fracture. This should be the nurse’s priority as it could lead to long-term damage if not addressed promptly.
Choice C rationale
A capillary refill time of less than 2 seconds is considered normal and is not a cause for immediate concern in a child with a femur fracture.
Choice D rationale
A respiratory rate of 24/min is within the normal range for a school-age child and is not a cause for immediate concern in a child with a femur fracture.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
It’s not advisable to follow the directions on the aspirin bottle for her age and weight. Aspirin is not recommended for use in children due to the risk of Reye’s syndrome, a rare but serious condition that can affect the liver and brain.
Choice B rationale
This is the correct response. Acetaminophen is a safer alternative to aspirin for managing fever in children.
Choice C rationale
While it’s generally a good idea to administer medication with food to prevent stomach upset, this advice does not address the specific risks associated with giving aspirin to a toddler.
Choice D rationale
Giving a toddler three baby aspirin every 4 hours is not recommended due to the risk of Reye’s syndrome.
Correct Answer is D
Explanation
Choice A rationale
While placing a pillow under the child’s head might seem like a good idea, it’s actually not recommended during a seizure. The child’s movements could be unpredictable, and a pillow could potentially cause suffocation.
Choice B rationale
Removing the child’s eyeglasses is a good idea, but it’s not the first thing you should do. The child’s safety is the top priority, and eyeglasses can be removed once the child is safe.
Choice C rationale
Timing the seizure is important for medical professionals to know, but it’s not the first action to take. The child’s immediate safety is the priority.
Choice D rationale
Moving the child into a side-lying position is the priority. This position helps keep the airway clear and allows any vomit to exit the mouth, reducing the risk of choking.
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