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 A
Explanation
Choice A rationale
A urine specific gravity of 1.034 is higher than the normal range (1.002-1.030), indicating that the urine is more concentrated due to a lack of hydration.
Choice B rationale
A bounding pulse is not typically associated with dehydration. Dehydration more commonly results in a weak, rapid pulse.
Choice C rationale
A blood pressure reading of 46/94 mm Hg is not indicative of dehydration. Dehydration often leads to low blood pressure.
Choice D rationale
Distended neck veins are not a typical sign of dehydration. Dehydration can lead to decreased blood volume, which would not cause distension of the neck veins.
Correct Answer is B
Explanation
Choice A rationale
Gastroesophageal Reflux Disease (GERD) in infants is a condition where the stomach contents flow back into the esophagus causing discomfort. However, the symptoms described, such as projectile vomiting and constant hunger, are more consistent with Pyloric Stenosis.
Choice B rationale
Pyloric Stenosis is a condition in infants where the opening from the stomach to the small intestine narrows, preventing food from entering the small intestine. The symptoms described by the parents, such as projectile vomiting after every feeding and constant hunger, align with this condition. The infant’s lack of weight gain could be due to the fact that food is not being properly digested and absorbed. The nurse should refer the infant for a surgical consultation as the treatment for Pyloric Stenosis is usually surgical. The nurse should monitor the infant’s weight and frequency of vomiting to assess the infant’s progress.
Choice C rationale
Lactose Intolerance in infants is a condition where the infant has difficulty digesting lactose, a sugar found in milk and dairy products. Symptoms can include gas, bloating, and diarrhea.
However, the symptoms described by the parents do not align with this condition.
Choice D rationale
Milk Protein Allergy in infants is a condition where the infant’s immune system reacts negatively to the proteins in cow’s milk. Symptoms can include hives, itching, wheezing, difficulty breathing, constipation, and bloody diarrhea. However, the symptoms described by the parents do not align with this condition.
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