A nurse is caring for a 9-year-old child at a clinic.
Vital Signs.
1000:. Temperature 36.8°C (98.2 °F). Heart rate 102/min.
Respiratory rate 22/min.
BP 100/60 mm Hg. Oxygen saturation is 98% on room air.
Nurses' Notes.
1000:.The child has been brought to the clinic by their parent due to a. report of right arm pain.
The parent states that several hours.
ago the child tripped and fell onto the sidewalk while playing.
outside.
The child states, "I was running when we were playing,and I tripped over a curb." The child is supporting their arm across.
their body.
Assessment.
1000:The child is alert and appears developmentally appropriate for their.
age and well nourished.
Respirations are easy and unlabored.
Abdomen nondistended.
The right forearm and fingers are edematous.
Ecchymotic area.
noted on the outer aspect of the forearm.
Radial pulse +2. Fingers.
slightly cool to the touch.
A child can move fingers and reports a mild.
"tingling" sensation.
The child verbalizes a pain level of 4 on a scale.
of 0 to 10. Abrasion noted on the right knee.
No active bleeding.
Multiple areas of bruising were noted on the lower extremities in various.
stages of healing.
The nurse should determine that the assessment findings are consistent with.
which of the following conditions? For each potential condition, click to specify if the assessment findings are.
consistent with a sprain, a fracture, or dislocation.
Each finding may support this.
more than 1 condition.
Sensation
Edema
Pain level
Ecchymosis
The Correct Answer is {"A":{"answers":"B,C"},"B":{"answers":"A,B,C"},"C":{"answers":"A,B,C"},"D":{"answers":"A,B,C"}}
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"}}
No explanation
Correct Answer is C
Explanation
Choice A rationale:
Checking the medical record for prior blood glucose test results is a task that can be delegated to the assistive personnel (AP). It provides relevant information for the nurse to assess the client's current condition. However, it is not the most crucial step in ensuring the safe performance of the blood glucose test.
Choice B rationale:
Asking the client if she has taken her antidiabetic medication today is important, but this task is better suited for the nurse, as it requires accurate communication with the client about their medication history and adherence. Delegating this task to the AP may lead to potential misunderstandings or errors in the information provided.
Choice C rationale:
The nurse should determine if the AP has the necessary skills and competence to perform the blood glucose test. Delegating tasks based on the competency of the staff member ensures the safety and well-being of the client. If the AP is not skilled in performing the test, the nurse should assign the task to someone else or perform the test personally.
Choice D rationale:
The nurse should not directly perform the blood glucose test if it can be safely delegated to the AP. Delegating appropriate tasks to competent staff members allows nurses to focus on more complex aspects of client care and ensures efficient use of resources within the healthcare team.
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