Nokea
A nurse is caring for a school-age child who has a fracture to the right femur. Which of the following findings is the nurse's priority?
- A. Capillary refill less than 2 seconds
- B. Tingling in the right foot
- C. 2+ right pedal pulse
- D. Respiratory rate 24/min
Correct Answer: B
Rationale: Tingling (paraesthesia) can be a sign of nerve damage or compromised circulation which may indicate complications such as compartment syndrome. This is a priority finding because it can lead to severe consequences if not addressed promptly.
You may also like to solve these questions
A nurse is reinforcing teaching with an adolescent who has type 1 diabetes mellitus. Which of the following instructions should the nurse include In the teaching?
- A. Inject insulin in the deltoid muscle.
- B. Take glyburide with breakfast.
- C. Obtain an influenza vaccine annually.
- D. Administer glucagon for hyperglycemia.
Correct Answer: C
Rationale: People with diabetes are at higher risk for complications from influenza so annual vaccination is recommended.
A nurse at a pediatric hotline receives a call from a mother who plans to administer aspirin to a toddler for a fever and wants to know the dosage. Which of the following statements by the nurse is an appropriate response?
- A. Give her acetaminophen, not aspirin.
- B. You'll have to call your physician.
- C. Follow the directions on the aspirin bottle for her age and weight.
- D. Give her no more than three baby aspirin every 4 hours.
Correct Answer: A
Rationale: Acetaminophen is commonly recommended for treating fever in children as it is safer and does not carry the risk of Reye's syndrome.
A school nurse is screening an 11-year-old child for idiopathic scoliosis. Which of the following instructions should the nurse give the child for this examination?
- A. Bend forward from the waist with your head and arms downward.
- B. Lie prone on the examination table.
- C. Touch your chin to your chest, and then look up at the ceiling.
- D. Turn to the side, and remain in a relaxed position.
Correct Answer: A
Rationale: This position known as the Adam's forward bend test is commonly used to screen for scoliosis.
A nurse is caring for an adolescent client who is receiving carbamazepine (Tegretol) for partial seizure disorder. Which of the following statements by the adolescent's parent is the priority for the nurse to address?
- A. He takes his medication between meals with water.
- B. He only sleeps about 5 hours each night.
- C. He seems to be getting a lot more bumps and bruises lately.
- D. He has not been eating as much lately.
Correct Answer: C
Rationale: Increased bruising can indicate thrombocytopeniaa potential side effect of carbamazepine which can lead to serious bleeding issues.
A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?
- A. Restrain the child's arms.
- B. Insert a padded tongue blade into the child's mouth.
- C. Place the child in a side-lying position.
- D. Elevate the child's legs on a pillow.
Correct Answer: C
Rationale: This helps maintain an open airway and allows for drainage of saliva or vomit reducing the risk of aspiration.