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?
Capillary refill less than 2 seconds.
Tingling in the right foot.
Respiratory rate 24/min.
2+ right pedal pulse.
The Correct Answer is B
Choice A rationale
Capillary refill less than 2 seconds is a normal finding and suggests adequate perfusion. It is not indicative of a priority concern in this context.
Choice B rationale
Tingling in the right foot can indicate nerve damage or compromised circulation, which is critical to address in a patient with a fracture. This symptom could suggest complications like compartment syndrome, requiring immediate medical attention.
Choice C rationale
Respiratory rate of 24/min is slightly elevated but not directly related to the fracture's immediate complications. It requires monitoring but is not the priority.
Choice D rationale
A 2+ right pedal pulse indicates a normal pulse and adequate circulation in the foot. While important, it does not represent an immediate concern in this context.
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Correct Answer is D
Explanation
A. Elevated blood pressure is not an indication of dehydration; dehydration is more likely to cause a drop in blood pressure due to decreased blood volume.
B. Dehydration typically does not cause a low body temperature; instead, it can lead to an elevated temperature as the body conserves water.
C. Jugular vein distention is associated with fluid overload or heart failure, not dehydration.
D. Skin tenting, where the skin remains elevated after being pinched, is a classic sign of dehydration due to reduced skin elasticity.
Correct Answer is C
Explanation
Choice A rationale
A properly fastened harness and securely anchored car seat are essential for infant safety. This statement indicates correct practice and does not require further teaching.
Choice B rationale
Using an infant model car seat that is securely anchored is appropriate for a 6-month-old infant. This statement is correct and does not indicate a need for further teaching.
Choice C rationale
A front-facing car seat is inappropriate for a 6-month-old infant. Infants should ride in a rear-facing car seat until at least the age of 2 or until they reach the highest weight or height allowed by the car seat manufacturer. This statement indicates a need for further teaching.
Choice D rationale
A rear-facing car seat in the back passenger seat is the safest position for a 6-month-old infant. This statement is correct and does not indicate a need for further teaching.