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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Related Questions
Correct Answer is D
Explanation
A. "I will immediately report irregular respirations." Irregular respirations can be normal in infants, as their breathing patterns are often irregular. Immediate reporting is not typically necessary unless there are other signs of distress.
B. "I will immediately report a respiratory rate of 28." A respiratory rate of 28 is low for a 1-month-old infant, but immediate reporting depends on the overall clinical picture and other signs of distress. Normal respiratory rates for this age are usually between 30-60 breaths per minute.
C. "I will count the baby's respirations for 30 seconds and multiply by two." While this method is used for older children and adults, it’s not ideal for infants due to their irregular breathing patterns. Counting for a full minute provides a more accurate assessment.
D. "I will count the baby's respirations by observing abdominal movements." This is correct. In infants, respiration is primarily diaphragmatic, making abdominal movements a reliable indicator of respiratory rate.
Correct Answer is D
Explanation
A. "I will provide low-fat meals for my child.": Children with cystic fibrosis need a high-calorie, high-fat diet to meet their increased energy needs and to help with growth and development due to malabsorption issues.
B. "I will restrict the amount of salt in my child's meals.": Children with cystic fibrosis tend to lose more salt through sweat and often require additional salt in their diet.
C. "I will put my child in daycare to ensure that she socializes with other children.": While socialization is important, children with cystic fibrosis are at higher risk for respiratory infections and should avoid environments where they are more likely to be exposed to pathogens.
D. "I will make sure my child washes her hands before eating.": Hand hygiene is crucial for preventing infections, which are a significant risk for children with cystic fibrosis due to their compromised lung function.
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