A nurse is contributing to the plan of care for an adolescent client.
Which of the following actions should the nurse identify as part of the plan of care? Select all that apply.
Provide oxygen at 6 L/min via nasal cannula.
Apply cold compresses to joints.
Perform passive ROM exercises.
Administer IV fluids
Obtain consent for a blood transfusion
Restrict fluid intake to 1,400 mL/day
Administer meperidine
Encouraging bedrest
Correct Answer : B,C,G,H
A. Providing oxygen at 6 L/min via nasal cannula is not indicated based on the information provided. The client denies shortness of breath, and vital signs are within normal limits.
B. Applying cold compresses to joints can help reduce swelling and alleviate pain in the extremities.
C. Performing passive range of motion (ROM) exercises is appropriate to maintain joint flexibility and prevent contractures.
D. Administering IV fluids is not explicitly indicated based on the information provided. Fluid management should be individualized based on the client's condition and underlying factors.
E. Obtaining consent for a blood transfusion is not necessary unless the client has severe anemia or bleeding.
F. Restricting fluid intake to 1,400 mL/day may cause dehydration and electrolyte imbalance.
G. Administering meperidine (a narcotic analgesic) may be considered for pain relief.
H. Encouraging bedrest is appropriate to minimize joint stress and promote healing, especially when there is pain and swelling in the extremities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["100"]
Explanation
To answer this question, we need to use the formula:
IV flow rate (gtt/min) = (Volume to be infused in mL x Drop factor in gtt/mL) / Time of infusion in minutes
Plugging in the given values, we get:
IV flow rate (gtt/min) = (100 mL x 60 gtt/mL) / 60 min Simplifying, we get:
IV flow rate (gtt/min) = 100 gtt/min
Therefore, the nurse should set the IV flow rate to deliver 100 gtt/min.
Correct Answer is C
Explanation
A. While blood pressure changes may occur with aging, it is not a direct cause of dehydration.
B. Older adults tend to have a decrease in the percentage of body water, contributing to a higher risk of dehydration.
C. Aging can lead to a decrease in renal function, affecting the body's ability to concentrate urine and conserve water.
D. Saliva production typically decreases with aging and is not a significant factor in dehydration.
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