A nurse is caring for a 9-year-old child at a clinic.
Select the 3 priority actions that the nurse should take.
Place a nonadherent dressing on the right knee abrasion.
Administer Ibuprofen 200 mg
Apply ice packs to the fingers and along the right forearm.
Elevate the affected forearm with pillows.
Review cast care instructions with the child's parents.
Explain the cast application procedure to the child.
Correct Answer : B,C,D
A. Place a nonadherent dressing on the right knee abrasion: While minor abrasions should be cleaned and dressed, it is not a priority compared to managing the child's pain and fracture care.
B. Administer Ibuprofen 200 mg: Ibuprofen is an appropriate analgesic and anti-inflammatory medication to manage the child's pain (rated 5/10) and reduce swelling. Prompt pain relief is essential for the child’s comfort.
C. Apply ice packs to the fingers and along the right forearm: Applying ice helps reduce edema, pain, and inflammation at the fracture site. It also minimizes soft tissue damage.
D. Elevate the affected forearm with pillows: Elevating the arm helps reduce swelling and promotes venous return, which is essential for minimizing discomfort and preventing complications like compartment syndrome.
E. Review cast care instructions with the child's parents: Reviewing cast care is essential but should be done after the cast is applied, not at this stage of care.
F. Explain the cast application procedure to the child: This is important but not an immediate priority. The nurse should first address pain, swelling, and proper limb positioning before discussing the procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Hemoglobin and hematocrit are important but not the focus in Alzheimer’s care unless anemia is suspected.
B. Liver function tests are not typically monitored unless the client is on hepatotoxic medications.
C. Kidney function tests are essential if there are concerns about hydration or medication clearance but are not routine in Alzheimer's care.
D. Monitoring serum sodium and potassium is critical as imbalances can lead to confusion, agitation, and worsening cognitive symptoms.
Correct Answer is D
Explanation
A. Monitoring every 30 minutes is insufficient; it should be more frequent.
B. Providers must evaluate the client within 1 hour of restraint initiation, not 36 hours.
C. Restraint prescriptions for adults must be renewed every 4 hours, not 6.
D. Documenting the client’s behavior every 15 minutes ensures continuous assessment and compliance with safety protocols.
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