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. "You should give your child's last daily dose of the medication before 6 o'clock in the evening." Methylphenidate is a stimulant, and giving it too late in the day can cause insomnia. Administering the last dose before 6 PM helps minimize sleep disturbances.
B. "You will need to give your child the medication after meals." Methylphenidate is typically given before meals to enhance its absorption and effectiveness. Taking it after meals is not recommended as it can delay absorption.
C. "You will need to have your child's blood glucose level checked monthly." There is no need for regular blood glucose monitoring unless the child has other conditions like diabetes. Methylphenidate does not typically affect blood glucose levels.
D. "You should not give your child the medication on weekends." Continuous use of methylphenidate is generally recommended to provide consistent symptom control, including on weekends. “Drug holidays” may be considered in specific cases but should be discussed with a healthcare provider.
Correct Answer is ["7"]
Explanation
Formula: Volumetoadminister=Desireddose/Availabledose ×Volumeavailable
Calculation: 350mg/250mg × 5mL=7mL
Answer: 7 mL
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