The nurse is checking for capillary refill on a child in Bryant's traction. How long does it take for the toe to regain color if adequate perfusion is assessed?
a. 3 seconds
b. 4 seconds
c. 5 seconds
d. 6 seconds
ANS: A
Capillary refill in 3 seconds or less is determined to be indicative of adequate perfusion.
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During a procedure to remove impacted cerumen, the nurse should be assessing the patient for which of the following most critical complications?
A) Excessive bleeding from the ear B) Pain related to instillation of warm fluids to soften the cerumen C) Symptomatic bradycardia from vagal nerve innervation D) Respiratory distress related to fluid entering bronchiole tubes
A school-age child had an upper respiratory tract infection for several days and then began having a persistent dry, hacking cough that was worse at night. The cough has become productive in the past 24 hours. This is most suggestive of
a. Bronchitis b. Bronchiolitis c. Viral-induced asthma d. Acute spasmodic laryngitis
Which assessment finding of a client requires the nurse's immediate action?
a. Being intubated for 4 days b. Uneven breath sounds c. Wheezing on auscultation d. Having the endotracheal (ET) tube taped to the lower jaw
An 89-year-old woman has developed urinary incontinence. The woman states, "When I have to go, I go. I can't make it to the bathroom before it leaks out." For which type of incontinence should the nurse develop a plan of care?
A) Functional incontinence B) Urge incontinence C) Mixed incontinence D) Stress incontinence