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 B
Explanation
Choice A rationale
Headache could indicate various conditions but is not immediately life-threatening post-surgery. It may be due to medication or anesthesia but is not the priority.
Choice B rationale
Altered level of consciousness (LOC) is a critical finding. It may indicate complications such as hemorrhage, fat embolism, or hypoxia, which require urgent assessment and intervention.
Choice C rationale
Muscle spasms can be a common symptom post-surgery due to pain or positioning. While they need management, they do not take precedence over LOC changes.
Choice D rationale
An oral temperature of 37.7°C is slightly elevated but not alarming. It may be due to the body's normal inflammatory response post-surgery.
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.