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.

Choice A rationale:

Give the client protamine if signs of magnesium sulfate toxicity occur. Protamine is not the antidote for magnesium sulfate toxicity. Calcium gluconate or calcium chloride is used to counteract the effects of magnesium sulfate toxicity by antagonizing the action of magnesium on the neuromuscular junction and the heart.

Choice B rationale:

Monitor the FHR via Doppler every 30 min. While fetal heart rate (FHR) monitoring is important during magnesium sulfate infusion due to the risk of fetal distress, using Doppler every 30 minutes may not provide continuous and accurate monitoring. Continuous electronic fetal monitoring is the standard of care in this situation.

Choice C rationale:

Restrict the client's total fluid intake to 250 mL/hr. Magnesium sulfate is excreted by the kidneys, so maintaining adequate urine output is crucial to prevent magnesium toxicity. Restricting fluid intake to 250 mL/hr would likely reduce urine output, leading to an increased risk of magnesium sulfate accumulation in the body, which could be harmful.

Choice D rationale:

Measure the client's urine output every hour. Monitoring urine output is essential during magnesium sulfate infusion as it helps assess renal function and magnesium excretion. Adequate urine output (at least 30 mL/hr) is necessary to prevent magnesium toxicity. Therefore, measuring the client's urine output every hour is a critical nursing intervention to ensure the safety of the client.

Choice A rationale:

The prescription for Levothyroxine 75 mcg PO daily at 0600 does not require clarification. It provides clear instructions for the medication, including the drug name, dosage, route, and timing. The administration time (0600) is specific, allowing the nurse to administer the medication accurately.

Choice B rationale:

The prescription for Digoxin 250 PO daily contains an error. The dosage (250) is missing the unit of measurement (e.g., mcg or mg). Without the unit, it is impossible to accurately administer the medication. This prescription needs clarification from the prescriber to ensure safe and precise administration.

Choice C rationale:

The prescription for Acetaminophen 650 mg PO Q6 hours does not require clarification. It provides clear instructions for the medication, including the drug name, dosage (650 mg), route (PO), and frequency (every 6 hours). The dosing interval is appropriate and within the normal range for acetaminophen administration.

Choice D rationale:

The prescription for Ceftriaxone 1 g IV Q 24 hours does not require clarification. It provides clear instructions for the medication, including the drug name, dosage (1 g), route (IV), and frequency (every 24 hours). The dosing interval is appropriate for this antibiotic and allows for effective treatment of infections.