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
Hypotension, or low blood pressure, is not typically associated with nephrotic syndrome. In fact, some patients with nephrotic syndrome may experience high blood pressure.
Choice B rationale
Generalized edema, or swelling, is a common characteristic of nephrotic syndrome. It occurs due to the loss of proteins in the urine, which leads to a decrease in the amount of protein in the blood. This decrease in blood protein levels causes fluid to move from the blood vessels into the tissues, leading to swelling.
Choice C rationale
Increased urinary output is not typically associated with nephrotic syndrome. In fact, some patients may experience decreased urine output.
Choice D rationale
Bright red blood in the urine is not a typical symptom of nephrotic syndrome. Hematuria, or blood in the urine, when present in nephrotic syndrome, is usually microscopic and not visible to the naked eye.
Correct Answer is B
Explanation
Choice A rationale
Regular blood sugar testing is crucial for managing type 1 diabetes. It helps the child and their caregivers monitor the child’s blood sugar levels and make necessary adjustments to their insulin doses or diet.
Choice B rationale
This statement indicates a need for additional teaching. Even when sick, it’s important for individuals with type 1 diabetes to continue taking their insulin. Illness often causes blood sugar levels to rise, so insulin is still needed.
Choice C rationale
Rotating injection sites can help prevent skin problems, such as lipodystrophy (a lump under the skin caused by the accumulation of extra fat at the site of many subcutaneous injections of insulin). Therefore, this is a correct practice.
Choice D rationale
Physical activity can lower blood sugar levels. Eating a snack before physical activities like playing soccer can help prevent hypoglycemia (low blood sugar). This is a correct understanding of managing physical activity with type 1 diabetes.
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