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. Avoid a diet consisting of primarily milk. Milk, especially cow’s milk, is low in iron and can inhibit iron absorption. Excessive milk consumption can also lead to iron deficiency anemia by displacing iron-rich foods from the diet and potentially causing gastrointestinal bleeding in infants. Limiting milk intake and ensuring a balanced diet can help prevent iron deficiency.
B. Include whole grains and legumes in the diet. Whole grains and legumes are good sources of nonheme iron, which is beneficial for preventing iron deficiency anemia. While this is a good dietary recommendation, infants might not consume enough of these foods to meet their iron needs without additional sources or supplements.
C. Administer fat-soluble vitamins daily. Rationale: Fat-soluble vitamins (A, D, E, K) are not directly related to preventing iron deficiency anemia. They are important for other aspects of health, but they do not address iron intake or absorption.
D. Limit intake of high-protein foods. Rationale: High-protein foods like meat are often rich in heme iron, which is easily absorbed and important for preventing anaemia. Limiting these foods would not be beneficial and might even contribute to anemia.
Correct Answer is D
Explanation
A. New onset of seizure disorder in the child's sibling: This does not contraindicate DTaP vaccination unless the child itself has a history of seizures or neurological disorders.
B. Evidence of sensitivity to egg antigens: DTaP vaccine is not contraindicated by egg allergy; this is more relevant to influenza vaccines.
C. Afebrile otitis media: This is not a contraindication for DTaP vaccination.
D. Temperature of 40.5° C (104.9° F) after last DTaP: A high fever following a previous dose of DTaP may indicate a severe reaction, necessitating caution or further evaluation before administering another dose.
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