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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?
- A. The parent reports the child will not keep the arm elevated on the pillow.
- B. The fingers on the right hand have a capillary refill of 4 seconds.
- C. The fingertips of the right hand are swollen and bruised.
- D. The child is not attempting to move her right arm or fingers.
Correct Answer: B
Rationale: A capillary refill time of more than 2 seconds indicates poor perfusion which can be a sign of compartment syndrome.
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A nurse is assisting with the care of a school-age child who has respiratory failure due to pneumonia. Which of the following positions should the nurse encourage to allow maximal lung expansion?
- A. Supine
- B. Prone
- C. Upright
- D. Side-lying
Correct Answer: C
Rationale: Sitting upright or in a high Fowler's position is optimal for lung expansion.
A nurse is caring for a toddler who is scheduled to have a lumbar puncture. Which of the following actions should the nurse take?
- A. Restrain the toddler for 1 hr after the procedure.
- B. Place the toddler in a side-lying
- C. knee-chest position.
- D. Ask another nurse to assist with holding the toddler in a prone position.
- E. Swaddle the toddler in a warm blanket.
Correct Answer: B
Rationale: This position helps to open the spaces between vertebrae, facilitating the lumbar puncture.
A nurse is caring for an infant who is dehydrated and requires IV therapy. The nurse should monitor the infant's response to therapy by performing which of the following actions?
- A. Taking the infant's vital signs every 2 hr
- B. Counting the number of wet diapers every shift
- C. Weighing the infant at the same time every day
- D. Measuring the infant's head circumference twice per day
Correct Answer: C
Rationale: Daily weights are a critical measure of fluid balance in infants. A consistent daily weight check provides a direct and accurate assessment of the infant's hydration status and response to IV therapy.
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 is reinforcing teaching with an assistive personnel (AP) about counting the respiratory rate for a 1-month-old infant. Which of the following statements by the AP indicates an understanding of the teaching?
- A. I will immediately report irregular respirations.
- B. I will immediately report a respiratory rate of 28.
- C. I will count the baby's respirations for 30 seconds and multiply by two.
- D. I will count the baby's respirations by observing abdominal movements.
Correct Answer: D
Rationale: In infants respiration is primarily diaphragmatic making abdominal movements a reliable indicator of respiratory rate.