A nurse is caring for a toddler who had a cast applied 2 hr ago due to multiple fractures of the right hand. Which of the following findings should the nurse report immediately to the charge nurse?
The parent reports the child will not keep the arm elevated on the pillow.
The fingers on the right hand have a capillary refill of 4 seconds.
The fingertips of the right hand are swollen and bruised.
The child is not attempting to move her right arm or fingers.
The Correct Answer is B
A. The parent reports the child will not keep the arm elevated on the pillow: Not a priority. While elevation is important, it is not immediately concerning.
B. The fingers on the right hand have a capillary refill of 4 seconds: Correct. A capillary refill time of more than 2 seconds indicates poor perfusion, which can be a sign of compartment syndrome, a serious complication.
C. The fingertips of the right hand are swollen and bruised: Concerning, but swelling and bruising can be normal post-injury. Immediate concern is perfusion.
D. The child is not attempting to move her right arm or fingers: Concerning, but can be due to pain or fear. Poor perfusion (B) is a more immediate threat.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is C
Explanation
A. Methylprednisolone: Methylprednisolone is a corticosteroid used to reduce inflammation in the airways. While effective in managing asthma, it has a slower onset of action and is used for longer-term management rather than immediate relief in acute situations.
B. Montelukast: Montelukast is a leukotriene receptor antagonist used for long-term control of asthma symptoms. It is not effective for immediate relief during an acute asthma attack because it takes time to exert its effects.
C. Albuterol: Albuterol is a short-acting beta-agonist that provides rapid bronchodilation. It is the first-line medication for immediate relief of bronchospasm during an acute asthma attack, making it the most appropriate choice for immediate administration.
D. Fluticasone: Fluticasone is an inhaled corticosteroid used for long-term asthma management and prevention of exacerbations. It is not suitable for immediate relief of an acute asthma attack as it does not act quickly enough to relieve bronchospasm.
Correct Answer is C
Explanation
Inject insulin in the deltoid muscle: Insulin is administered subcutaneously, not intramuscularly. Common sites for insulin injection include the abdomen, thighs, and upper arms.
B. Take glyburide with breakfast: Glyburide is an oral hypoglycemic agent used for type 2 diabetes, not type 1 diabetes. Adolescents with type 1 diabetes require insulin.
C. Obtain an influenza vaccine annually: People with diabetes are at higher risk for complications from influenza, so annual vaccination is recommended to prevent illness.
D. Administer glucagon for hyperglycemia: Glucagon is used to treat severe hypoglycaemia, not hyperglycaemia. For hyperglycemia, insulin administration and monitoring blood glucose levels are key.
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