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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.

Which of the following actions should the nurse take after the adolescent returns from surgery?

Select all that apply.

Remove indwelling urinary catheter when no longer indicated

Elevate affected limb at chest level

Assist the adolescent with ambulation from bed to chair

Perform neurovascular assessments every hour

Apply warm packs to right extremity for the first 24hrs

Answer and Explanation

Correct Answer : A,B,D

The correct answers are A, B, and D.

Choice A reason:

Removing an indwelling urinary catheter when it is no longer indicated is a standard postoperative care practice. It helps to reduce the risk of urinary tract infections (UTIs), which are common complications associated with prolonged catheter use. The normal practice is to remove the catheter as soon as the patient can use the bathroom independently or when medically advised.

Choice B reason:

Elevating the affected limb at chest level can help reduce swelling and improve venous return. This is particularly important after surgery involving the lower extremities to prevent edema and promote circulation. Proper elevation assists in managing pain and preventing complications such as deep vein thrombosis (DVT).

Choice C reason:

Assisting with ambulation from bed to chair immediately after surgery may not be appropriate, especially if the adolescent has had surgery on the lower extremity. It is essential to wait for the physician's evaluation and specific instructions regarding weight-bearing and movement post-surgery.

Choice D reason:

Performing neurovascular assessments every hour is crucial after surgery on an extremity. This involves checking for sensation, motor function, color, temperature, capillary refill, and pulse strength. The normal capillary refill time is less than 2 seconds; a refill time of 4 seconds, as noted in the assessment, is abnormal and warrants close monitoring. Frequent assessments help in early detection of complications such as compartment syndrome.

Choice E reason:

Applying warm packs to the right extremity for the first 24 hours post-surgery is not recommended. Warm packs can increase circulation to the area, potentially increasing swelling and bleeding. Instead, cold packs are usually applied to reduce swelling and provide pain relief. The use of warm packs can be considered after the initial 24-hour period, depending on the surgeon's instructions and the wound's response.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

- A. Incorrect. Evaluating dietary intake requires nursing judgment and knowledge of nutrition and eating disorders. This task should not be delegated to an AP.

- B. Incorrect. Measuring vital signs of a postoperative client requires nursing assessment and monitoring for complications. This task should not be delegated to an AP.

- C. Correct. Arranging the lunch tray for a client who has a hip fracture is a routine task that does not require nursing skills or judgment. This task can be delegated to an AP.

- D. Incorrect. Assessing I&O for a client who is receiving dialysis requires nursing knowledge of fluid and electrolyte balance and renal function. This task should not be delegated to an AP.

A. Telephone number. B. Place of birth. C. Driver license number. D. Room number.

Correct Answer is A

Explanation

Choice A rationale:

The nurse should use the client's telephone number or another unique identifier, such as a medical record number or a unique identification code, to confirm the client's identity before administering medication. Using a telephone number or a unique identifier ensures accurate identification of the client and helps prevent medication errors.

Choice B rationale:

Place of birth is not a suitable identifier for confirming a client's identity. It does not provide specific and accurate information about the individual and may not be unique to the client.

Choice C rationale:

Driver license number is not a suitable identifier for confirming a client's identity. It may not be readily available in the healthcare setting, and not all clients have a driver's license. Using this identifier could lead to identification errors.

Choice D rationale:

Room number is not a suitable identifier for confirming a client's identity. Room numbers are not unique to individual clients and can change based on hospital assignments. Relying on room numbers can lead to confusion and medication errors.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Correct Answer is C

Explanation

A nurse is preparing to administer medication to a client. Which of the following identifiers should the nurse use to identify the client?

Correct Answer is A

Explanation

A charge nurse is speaking with the partner of a client. The partner states that the client is not receiving adequate care. Which of the following actions should the charge nurse take first to resolve the situation?

A nurse is caring for a client who is receiving positive end-expiratory pressure (PEEP) via mechanical ventilation. The nurse should monitor the client for which of the following adverse effects of PEEP?

A nurse has received change-of-shift report on four assigned clients. For which of the following clients should the nurse intervene to prevent a potential food and medication interaction?

A nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the client's family to obtain consent. Which of the following actions should the nurse take?

A nurse is assessing a client for allergies prior to administering the influenza vaccine.The nurse should identify that an allergy to which of the following foods is a contraindication to receiving this vaccine?

A nurse is preparing to teach about dietary management to a client who has Crohn's disease and an enteroenteric fistula. Which of the following nutrients should the nurse instruct the client to decrease in their diet?

A nurse is performing an admission assessment of a school-age child who has spina bifida.The parent states that the child is allergic to latex.The nurse should assess further for cross-sensitivity to which of the following foods?

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