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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A. Radial vein of the inner arm. This is correct because this site is easily accessible, has good blood flow, and has less risk of complications such as infection, thrombosis, or infiltration.

B. Great saphenous vein of the leg. This is incorrect because this site is not recommended for older adults due to poor circulation, increased risk of thrombophlebitis, and difficulty in monitoring.

C. Dorsal plexus vein of the foot. This is incorrect because this site is prone to edema, infection, and injury, and can interfere with mobility and comfort.

D. Basilic vein of the hand. This is incorrect because this site is more painful, has smaller veins, and can cause nerve damage or occlusion if not inserted carefully.

A. Discuss the suspicion of physical abuse with the provider. B. Confront the parents with the suspicion of physical abuse. C. Ask the hospital security to detain and question the parents. D. Contact Child Protective Services.

Correct Answer is D

Explanation

A. Discussing the suspicion of physical abuse with the provider isis essential, but it should not replace reporting to CPS. The provider’s input is valuable, but immediate action is necessary.

B. Confronting the parents with the suspicion of physical abuse is not an appropriate action for the nurse to take, as it can escalate the situation and endanger the child or the nurse.

C. Asking the hospital security to detain and question the parents is not an appropriate action for the nurse to take, as it violates the parents' rights and may interfere with the legal process.

D. Contacting Child Protective Servicesnurses are legally required to report all cases of suspected child abuse to the appropriate local or state agency.It's a critical step in protecting the child from further harm.

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client?

Correct Answer is A

Explanation

A nurse in an emergency department is assessing a school-age child who was brought in by their parents and has scald burns to both hands and wrists. The nurse suspects physical abuse. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is giving an intramuscular injection to a newborn who was delivered at 38 weeks of gestation. Which of the following pain scales should the nurse use to assess the newborn's pain?

The practical nurse (PN) observes a newly hired unlicensed assistive personnel (UAP) who is counting a client's radial pulse as seen in the picture. Which action should the PN take?

The practical nurse (PN) observes an unlicensed assistive personnel (UAP) performing oral hygiene on an unconscious client who is lying in a ﬂat side-lying position with an emesis basin on the bedside table near the chin. Which action should the PN take?

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