A nurse is caring for a toddler who has a short leg cast. Which of the following findings should the nurse report to the provider?
Warm temperature of the distal extremity
Positive pedal pulse in the distal extremity
Pallor of the distal extremity
Mobility of the distal extremity
The Correct Answer is C
A. Warm temperature of the distal extremity: Warmth is a normal finding and indicates proper blood flow to the extremity.
B. Positive pedal pulse in the distal extremity: A positive pedal pulse is a good sign indicating that circulation is adequate in the extremity.
C. Pallor of the distal extremity: Pallor can indicate compromised blood flow or ischemia, which is a serious condition that needs immediate attention. This could be a sign that the cast is too tight or that there is another issue affecting circulation.
D. Mobility of the distal extremity: Mobility of the distal extremity indicates that the cast is not too tight and that nerve function is likely intact. It is a positive sign and generally not a concern unless there are other symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. An adolescent who has a BP of 132/82 mm Hg: While on the higher end of normal for adolescents, it might not necessarily require immediate reporting unless there are other symptoms or a history of hypertension.
B. A 3-month-old infant who has a respiratory rate of 30/min: A respiratory rate of 30/min is within the normal range for a 3-month-old infant. Normal respiratory rates for infants typically range from 30 to 60 breaths per minute
C. A school-age child who has a rectal body temperature of 37.3° C (99.1° F): This is a low-grade fever and might not be a major concern in an otherwise healthy school-age child.
D. An 18-month-old toddler who has a heart rate of 68/min: A heart rate of 68/min is lower than the normal range for an 18-month-old toddler. Typically, the normal heart rate for toddlers ranges from about 80 to 130 beats per minute. A heart rate of 68/min could indicate bradycardia, which requires further assessment by a provider.
Correct Answer is C
Explanation
a. Mix the medication with the child's favorite food. Mixing medication with a child’s favorite food can be risky as it may alter the taste of the food and cause the child to develop an aversion to that food. Additionally, if the child does not consume the entire portion, they may not receive the full dose of medication.
b. Dilute the medication with 8 oz of water. Diluting medication in a large volume of water is not advisable for a preschooler as it may be difficult for them to drink the entire amount, leading to an incomplete dose. It can also dilute the medication to the point where its efficacy is reduced.
c. Provide an ice pop after administering the medication. Offering an ice pop after administering the medication is a positive reinforcement technique. The ice pop can also help numb the taste buds, reducing the aftertaste of the medication, making it more acceptable for the child.
d. Give 4 oz of milk with the medication.Giving milk with medication is not generally recommended as it can interfere with the absorption of some medications. Additionally, if the medication tastes unpleasant, the child might refuse to drink the milk as well.
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