A nurse is caring for a toddler who had a cast applied 2 hours ago due to multiple fractures of the right hand.
Which of the following findings should the nurse report immediately to the charge nurse?
The child is not attempting to move her right arm or fingers.
The fingertips of the right hand are swollen and bruised.
The fingers on the right hand have a capillary refill of 4 seconds.
The parent reports the child will not keep the arm elevated on the pillow.
The Correct Answer is C
A nurse caring for a toddler who had a cast applied 2 hours ago due to multiple fractures of the right hand should report immediately to the charge nurse if the fingers on the right hand have a capillary refill of 4 seconds.
This could indicate that there is a problem with circulation.
Choice A is not an answer because it is not unusual for a child to not attempt to move her right arm or fingers after having a cast applied.
Choice B is not an answer because it is not unusual for the fingertips of the right hand to be swollen and bruised after having a cast applied.
Choice D is not an answer because it is not unusual for a child to not keep their arm elevated on a pillow after having a cast applied.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse observes Brittny during meal times and for 2 hours after eating to monitor for purging behaviors.
Choice A is incorrect because building a trusting relationship with the patient is important but not the primary reason for observing the patient during meal times and for 2 hours after eating.
Choice C is incorrect because teaching about nutrition is important but not the primary reason for observing the patient during meal times and for 2 hours after eating.
Choice D is incorrect because taking a break with the patient is not the primary reason for observing the patient during meal times and for 2 hours after eating.
Correct Answer is D
Explanation
“Implantation occurs between two and three weeks after conception.” This statement is incorrect because implantation usually occurs about 6 to 10 days after conception.
Choice A is correct because bleeding or spotting can accompany implantation.
Choice B is correct because sperm can remain viable in the woman’s reproductive tract for 2 to 3 days.
Choice C is correct because fertilization typically takes place in the outer third of the fallopian tube.
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