A nurse is caring for an adolescent.
Admission Assessment
1400:

Adolescent brought to emergency department by parents following a fall while skateboarding.

Adolescent reports pain in their right leg as 10 on a scale of 0 to 10 and is unable to bear weight.

Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm.

Abdomen soft and nontender with active bowel sounds in all four quadrants.

Right lower extremity with open wound and displaced bone.

Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds.

Select the 4 findings that require follow-up.

Blood pressure

Capillary refill

Pedal pulse

Heart rate

Skin temperature

Pain

Answer and Explanation

Correct Answer : B,C,E,F

A. Blood pressure: A normal blood pressure for an adolescent is 110/70 mm Hg. The question does not provide the adolescent's blood pressure, so it cannot be determined if it requires follow-up or not.
B. Capillary refill: A normal capillary refill time is less than 2 seconds. A prolonged capillary refill time indicates impaired blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
C. Pedal pulse: A normal pedal pulse is +2 or +3. A weak pedal pulse (+1) indicates reduced blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.

D. Heart rate: A normal heart rate for an adolescent is 60 to 100 beats per minute. The question does not provide the adolescent's heart rate, so it cannot be determined if it requires follow-up or not.
E. Skin temperature: A normal skin temperature is warm and dry. A cool skin temperature indicates reduced blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
F. Pain: A pain level of 10 on a scale of 0 to 10 indicates severe pain that needs to be managed with appropriate analgesics and nonpharmacological interventions.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. This is correct because discomfort while walking can indicate genital trauma or infection, which are possible signs of sexual abuse.
B. This is incorrect because thin extremities can be caused by many factors, such as malnutrition, genetic disorders, or chronic diseases, that are not necessarily related to sexual abuse.
C. This is incorrect because bruises on the upper back can result from accidental injuries, such as falls or bumps, or from physical abuse, such as hitting or kicking, but not specifically from sexual abuse.
D. This is incorrect because a stained shirt can be due to poor hygiene, food spills, or environmental factors, but not necessarily from sexual abuse.

A. Check the client's blood type and crossmatch it against the provider's orders. B. Ask the client to state their blood type prior to beginning blood administration. C. Compare information on the blood product to the informed consent form. D. Verify the client and blood product information with another licensed nurse.

Correct Answer is D

Explanation

A. This is not a correct procedure for client identification, but rather for blood compatibility. The nurse should check the client's blood type and crossmatch it against the blood product label, not the provider's orders.
B. This is not a reliable method of client identification, as the client may not know or remember their blood type correctly. The nurse should use two identifiers, such as name and date of birth, to confirm the client's identity.
C. This is not a relevant step for client identification, but rather for informed consent. The nurse should ensure that the client has signed an informed consent form before administering blood, but this does not verify that the blood product matches the client.
D. This is the correct procedure for client identification, as it involves two licensed nurses who independently check and confirm the client's identity and the blood product information, such as blood type, Rh factor, expiration date, and serial number.

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Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is assessing a preschooler who has a facial laceration. The nurse should identify which of the following findings as a potential indication of child sexual abuse?

Correct Answer is A

Explanation

A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures should the nurse follow to ensure proper client identification?

Correct Answer is D

Explanation

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