A nurse is caring for a 9-year-old client at a clinic.
Select 3 priority actions that the nurse should take.
Apply ice packs to the fingers and along the right forearm.
Review cast care instructions with the child's parents.
Place a nonadherent dressing on the right knee abrasion.
Administer Ibuprofen 200 mg PO.
Explain the cast application procedure to the child.
Elevate the affected forearm with pillows.
Correct Answer : A,D,F
A. Ice helps reduce pain and swelling by causing vasoconstriction and minimizing tissue inflammation. Application should be intermittent (20 minutes on, 20 minutes off) and wrapped to avoid direct skin contact. Early ice therapy supports circulation preservation and limits edema progression.
B. The child has not yet received a cast; teaching about cast care is premature. Priority actions now are to stabilize, relieve pain, and control swelling before immobilization.
C. While wound care is appropriate, this is not a priority compared to interventions preventing neurovascular impairment in the fractured arm.
D. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that helps reduce both pain and inflammation. Administering analgesics promptly improves comfort and facilitates cooperation with care. Pain control is essential for monitoring neurovascular changes, as uncontrolled pain can mask worsening symptoms.
E. Although preparation reduces anxiety, this step should occur after the client’s comfort and circulation are stabilized. The immediate focus should be on pain and swelling management.
F. Elevation promotes venous return and reduces edema, minimizing pressure on surrounding tissues. The limb should be elevated above heart level unless contraindicated. This helps prevent circulatory compromise and supports healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
Rationale:
A. Heart rate decreased from 110/min on day 3 to 78/min on day 5. Tachycardia is a common response to fever and infection. The return to normal heart rate indicates resolution of infection and improved systemic status.
B. Temperature decreased from 38.6°C (101.5°F) to 37.1°C (98.9°F). Afebrile status reflects infection resolution and successful antibiotic response.
C. Fundus descended from 1 cm above umbilicus (day 3) to 4 cm below umbilicus (day 5). Normal uterine involution should occur at about 1 cm/day; this finding confirms proper healing and uterine contraction.
D. WBC count decreased from 33,000/mm³ to 10,000/mm³, which is within the normal range (5,000–10,000/mm³). This indicates infection control and resolution of systemic inflammation.
E. Lochia changed from dark brown and foul-smelling to small amount of brownish-red lochia without odor. The progression and normalization of lochia color and odor indicate healing and resolution of uterine infection.
F. Hemoglobin (Hgb) decreased from 11.1 g/dL to 10 g/dL, indicating continued mild anemia likely related to blood loss from delivery or infection recovery. Although the drop is slight, it does not indicate clinical improvement.
Correct Answer is D
Explanation
A. Cheyne-Stokes respirations: This is a common sign of approaching death but not necessarily an indication for pain medication.
B. Constricted pupils: This may indicate opioid use or neurological changes, not pain.
C. Mottled skin: Mottling occurs as circulation declines near the end of life, not specifically due to pain.
D. Restlessness: In palliative care, restlessness is often a sign of pain or discomfort, even if the client cannot verbalize pain. The nurse should administer prescribed pain medication to ensure comfort.
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