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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.

Capillary refill less than 2 seconds.

B.

Tingling in the right foot.

C.

Respiratory rate 24/min.

D.

2+ right pedal pulse.

Answer and Explanation

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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View Related questions

Correct Answer is B

Explanation

Choice A rationale

Learning to use creative energies relates to the initiative vs. guilt stage, aimed at preschool children, where they begin asserting power and control over their world through play and social interactions.

Choice B rationale

Defining a sense of self is a task during the identity vs. role confusion stage in adolescence. Adolescents work on discovering who they are by exploring beliefs, values, and goals to create a consistent and unique identity.

Choice C rationale

Building a sense of trust is a task during the trust vs. mistrust stage of infancy. Infants need reliable caregiving to develop trust in their environment and the people around them.

Choice D rationale

Learning to perform tasks independently occurs in the autonomy vs. shame and doubt stage, which is observed in toddlers. This stage is about children gaining confidence in their abilities to perform basic tasks on their own.

Correct Answer is A

Explanation

Choice A rationale

The hepatitis B vaccine is recommended for all newborns within 24 hours of birth to provide early protection against the hepatitis B virus.

Choice B rationale

The PCV (Pneumococcal Conjugate Vaccine) is administered as a series of four doses, typically at 2, 4, 6, and 12-15 months of age.

Choice C rationale

The first dose of the DTaP (Diphtheria, Tetanus, and Pertussis) vaccine is typically given at 2 months of age, not during the initial well-baby visit after birth.

Choice D rationale

The MMR (Measles, Mumps, and Rubella) vaccine is recommended at 12-15 months of age and again at 4-6 years, not at 6 months.

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