How it Works
Try Naxlex NCLEX-RN (Free-Trial)

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.

2+ right pedal pulse

B.

Tingling in the right foot

C.

Capillary refill less than 2 seconds

D.

Respiratory rate 24/min

Answer and Explanation

The Correct Answer is B

Choice A rationale
A 2+ right pedal pulse indicates a normal pulse and is not a cause for immediate concern in a child with a femur fracture.
Choice B rationale
Tingling in the right foot could indicate nerve damage or compromised blood flow, which can be a serious complication of a femur fracture. This should be the nurse’s priority as it could lead to long-term damage if not addressed promptly.
Choice C rationale
A capillary refill time of less than 2 seconds is considered normal and is not a cause for immediate concern in a child with a femur fracture.
Choice D rationale
A respiratory rate of 24/min is within the normal range for a school-age child and is not a cause for immediate concern in a child with a femur fracture.
 


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is A

Explanation

Choice A rationale
Activated charcoal is often used in the management of poisoning. It works by binding to the poison in the stomach and preventing it from being absorbed into the body14.
Choice B rationale
Osmotic diarrheal agents are not typically used in gastric lavage. These agents work by increasing the amount of water in the intestinal tract, which can stimulate bowel movements14.
Choice C rationale
Syrup of ipecac was once used to induce vomiting in cases of poisoning, but it is no longer recommended for use in poisoning cases14.
Choice D rationale
0.9% sodium chloride, or normal saline, is a type of fluid that’s often used in medical treatments, but it’s not typically used in gastric lavage for poisoning14.

Correct Answer is C

Explanation

Choice A rationale
While maintaining a saline-lock can be important for administering medications or fluids, it is not the priority action. The nurse’s priority should be to assess the child’s condition and intervene to prevent complications.
Choice B rationale
A no-salt-added diet may be recommended for some children with acute glomerulonephritis to help manage fluid balance and blood pressure. However, this is not the priority action. The nurse’s priority should be to assess the child’s condition and intervene to prevent complications.
Choice C rationale
This is the correct answer. Checking the child’s weight daily is a priority action because weight changes can indicate fluid retention or loss, which can affect kidney function. Regular weight checks can help guide treatment decisions and monitor the effectiveness of interventions.
Choice D rationale
Educating the parents about potential complications is important, but it is not the priority action. The nurse’s priority should be to assess the child’s condition and intervene to prevent complications.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register