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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
It is not advisable for a parent to attempt to reinsert the tubes if they fall out. This could potentially cause harm to the child’s ear.
Choice B rationale
If the tubes fall out, the parent should call the healthcare clinic to report this. The healthcare provider can then decide on the appropriate next steps.
Choice C rationale
It is not accurate to reassure the mother that the tubes will not fall out. Tympanostomy tubes are designed to fall out on their own after a certain period of time.
Choice D rationale
Taking the child to an emergency department is not necessary unless there are signs of infection or other complications.
Correct Answer is A
Explanation
Choice A rationale
Projectile vomiting is a common symptom in infants with pyloric stenosis. This is due to the narrowing of the pylorus, the muscular valve at the bottom of the stomach, which prevents breast milk or formula from passing through to the small intestine.
Choice B rationale
Effortless regurgitation is not typically associated with pyloric stenosis. The hallmark symptom of pyloric stenosis is projectile vomiting.
Choice C rationale
Metabolic acidosis is not a typical symptom of pyloric stenosis. The hallmark symptom of pyloric stenosis is projectile vomiting.
Choice D rationale
While a distended abdomen can occur in some cases of pyloric stenosis, it is not the most common symptom. The hallmark symptom of pyloric stenosis is projectile vomiting.
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