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
“6 weeks after fertilization.” Teratogens can begin affecting the developing embryo as early as 10 to 14 days after conception 1.
During embryonic development, there are periods when the developing organ systems show more sensitivity to teratogens.
Choice A is incorrect because 18 weeks after fertilization is not the earliest stage of pregnancy when exposure to a teratogenic agent could occur.
Choice C is incorrect because 12 weeks after fertilization is not the earliest stage of pregnancy when exposure to a teratogenic agent could occur.
Choice D is incorrect because this is not an incomplete question/stem.
Correct Answer is D
Explanation
Fever is a sign of infection and can indicate that there is an infection at the pin sites.
Choice A is not correct because warmth can be a normal finding at the pin sites.
Choice B is not correct because mild erythema can be a normal finding at the pin sites.
Choice C is not correct because serosanguineous drainage can be a normal finding at the pin sites.
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