A nurse is caring for a toddler who had a cast applied 2 hours ago due to multiple fractures of the right hand.
Which of the following findings should the nurse report immediately to the charge nurse?
The child is not attempting to move her right arm or fingers.
The fingertips of the right hand are swollen and bruised.
The fingers on the right hand have a capillary refill of 4 seconds.
The parent reports the child will not keep the arm elevated on the pillow.
The Correct Answer is C
A nurse caring for a toddler who had a cast applied 2 hours ago due to multiple fractures of the right hand should report immediately to the charge nurse if the fingers on the right hand have a capillary refill of 4 seconds.
This could indicate that there is a problem with circulation.
Choice A is not an answer because it is not unusual for a child to not attempt to move her right arm or fingers after having a cast applied.
Choice B is not an answer because it is not unusual for the fingertips of the right hand to be swollen and bruised after having a cast applied.
Choice D is not an answer because it is not unusual for a child to not keep their arm elevated on a pillow after having a cast applied.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is known as the Adams Forward Bend Test and is a standard screening test for scoliosis.
Choice A is incorrect because touching the chin to the chest and looking up at the ceiling does not provide a view of the spine necessary for scoliosis screening.
Choice C is incorrect because turning to the side and remaining relaxed does not provide a view of the spine necessary for scoliosis screening.
Choice D is incorrect because lying prone on the examination table does not provide a view of the spine necessary for scoliosis screening.
Correct Answer is A
Explanation
This statement shows empathy and support for the client.
It also encourages the client to engage in self-care activities and promotes independence.
Choice B is not appropriate because it is a threat and does not show empathy or support for the client.
Choice C is not appropriate because it encourages the client to remain passive and does not promote independence.
Choice D is not appropriate because it is confrontational and does not show empathy or support for the client.
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