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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "My baby's fingers are looking swollen.": Swelling around the IV site can indicate infiltration, where IV fluids leak into surrounding tissues rather than being infused into the vein.
B. "The tape is coming off the IV needle.": While loose tape may need to be replaced, it does not specifically indicate infiltration.
C. "There's blood backing up my baby's IV tubing.": Blood backflow can indicate various issues such as improper placement or the IV being too low, but not necessarily infiltration.
D. "There's a long red streak up my baby's arm.": A red streak can indicate phlebitis, inflammation of the vein, rather than infiltration, which typically presents with swelling and coolness around the IV site.
Correct Answer is B
Explanation
A. "I will notify the doctor if his temperature is not controlled with acetaminophen." Notifying the doctor if the temperature is not controlled with acetaminophen is appropriate, as persistent fever might indicate a more severe infection or other complications.
B. "I will continue to check his blood sugar two times every day." Checking blood sugar only twice a day is insufficient during illness, especially for a child with type 1 diabetes. Blood glucose levels can fluctuate significantly due to infection, and more frequent monitoring (at least 4 times a day or as recommended) is necessary.
C. "I will report changes in breathing or signs of confusion." Reporting changes in breathing or signs of confusion is essential, as these can be signs of worsening infection, respiratory distress, or diabetic ketoacidosis, which requires immediate medical attention.
D. "I will encourage him to drink a half a cup of water or sugar-free fluid every 30 minutes." Encouraging fluid intake is important to prevent dehydration and help manage blood glucose levels during illness. Ensuring adequate hydration with water or sugar-free fluids is appropriate.
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