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A nurse is caring for a 9-year-old client at a clinic.

Exhibits

The nurse reviews the assessment findings.

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Assessment

Respirations easy and unlabored. Abdomen nondistended. Right forearm and fingers are edematous. Ecchymotic area noted on outer aspect of the forearm. Radial pulse +2. Fingers slightly cool to touch. Child can move fingers and reports a mild "tingling" sensation. Child verbalizes a pain level of 4 on a scale of 0 to 10. Multiple areas of bruising noted on lower extremities in various stages of healing.

Exhibit 3

Vital Signs

1000:

Temperature 36.80 C (98.20 F)

Heart rate 102/min

Respiratory rate 22/min

BP 100/60 mm Hg

Oxygen saturation 98% on room air

Right forearm and fingers are edematous.

Radial pulse +2

Fingers slightly cool to touch

Child can move fingers and reports a mild "tingling" sensation

Child verbalizes a pain level of 4 on a scale of 0 to 10

Multiple areas of bruising noted on lower extremities in various stages of healing

Heart rate 102/min

Respiratory rate 22/min

Answer and Explanation

The Correct Answer is ["A","C","D","E"]

Findings Requiring Immediate Follow-Up

Right forearm and fingers are edematous: Swelling after trauma can indicate a fracture, soft tissue injury, or early compartment syndrome. Edema can compromise circulation and should be assessed promptly.

Fingers slightly cool to touch: Cool fingers may indicate reduced perfusion to the extremity, which is concerning after trauma. Immediate assessment of capillary refill, color, and temperature is necessary.

Child verbalizes a pain level of 4/10: Pain in children, even moderate, requires attention because it can indicate significant underlying injury and may escalate. Pain assessment and management should be prioritized.

Child can move fingers and reports a mild "tingling" sensation: Tingling may indicate nerve involvement or early neurovascular compromise, even if movement is preserved. Timely evaluation is essential.

Findings Not Requiring Immediate Follow-Up

Radial pulse +2: A +2 radial pulse is normal and indicates adequate arterial flow, so it does not require immediate intervention.

Multiple areas of bruising noted on lower extremities in various stages of healing: In this scenario, the bruising is assumed to be from normal childhood activity or minor trauma. It does not automatically signify abuse and is not an urgent concern.

Heart rate 102/min: Slightly elevated heart rate may reflect pain or stress. It is within normal limits for a 9-year-old (70–120/min).

Respiratory rate 22/min: Within normal range for a 9-year-old (18–26/min) and not urgent.

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Free Nursing Study Resources

Correct Answer is ["A","C"]

Explanation

A. Marking the drainage output on the collection chamber at regular intervals helps track trends in drainage volume and detect complications such as sudden increases (possible hemorrhage) or decreases (possible obstruction).

B. The collection chamber should always be kept below the level of the chest to promote drainage and prevent backflow of fluid into the pleural space.

C. Adding sterile water to the water seal chamber as it evaporates maintains the proper fluid level (usually 2 cm). This ensures the water seal remains intact to prevent air from re-entering the pleural space.

D. Clamping the chest tube routinely can cause a buildup of air and tension pneumothorax. It should only be done briefly when changing the drainage system or assessing for leaks under provider direction.

E. Stripping the tube vigorously creates excessive negative pressure, which can damage lung tissue and disrupt the pleural seal. It is contraindicated.

A. Encourage the client to attend a group therapy session. B. Continue to monitor the client every 15 min. C. Remove the restraints from the client. D. Offer the client PRN pain medication.

Correct Answer is C

Explanation

Rationale:

A. Group therapy can be beneficial later in treatment, but the priority now is to remove restraints once they are no longer necessary to ensure client safety and dignity.

B. Monitoring every 15 minutes is appropriate while restraints are in place, but once the client is calm and cooperative, restraints should be discontinued.

C. Restraints must be removed as soon as the client demonstrates control and is no longer a danger to self or others. This aligns with ethical and legal standards that require the least restrictive intervention possible.

D. PRN pain medication is not indicated unless there is a specific complaint of pain. The nurse’s priority is to remove restraints safely.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has a chest tube. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

Correct Answer is ["A","C"]

Explanation

A nurse is assessing a client who was placed in restraints for aggressive behavior. The client is now calm and cooperative. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is developing a care plan for a client who is in Buck's traction and scheduled for surgery for a fractured femur of the right leg. Which of the following interventions should the nurse delegate to an assistive personnel?

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?

A nurse is preparing to provide a change-of-shift report. Which of the following information should the nurse include in the report?

A nurse is supervising an assistive personnel (AP) who is caring for a client with an indwelling urinary catheter. Which of the following actions taken by the AP indicates proper technique?

A nurse in a clinic is caring for an adolescent client who is at 24 weeks of gestation and showing signs of preeclampsia. Which of the following findings should the nurse expect?

A nurse is caring for a client who has major depressive disorder. Which of the following findings should indicate to the nurse that the client's condition is improving?

A nurse is caring for a client who is pregnant. Exhibits The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.