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 ["94"]
Explanation
To answer this question, we need to use the formula: mL/hr = total volume (mL) / total time (hr). In this case, the total volume is 750 mL and the total time is 8 hr.
Plugging these values into the formula, we get: mL/hr = 750 / 8. Simplifying this fraction, we get: mL/hr = 93.75.
Since we need to round to the nearest whole number, the final answer is: mL/hr = 94. Therefore, the nurse should set the IV pump to deliver 94 mL/hr.
Correct Answer is ["0.6"]
Explanation
To calculate the dosage of diphenhydramine, the nurse needs to use the formula D/H x Q
= X, where D is the desired dose, H is the on-hand dose, Q is the quantity of the on-hand dose, and X is the amount to administer. In this case, D is 30 mg, H is 50 mg/mL, and Q is 1 mL. Plugging these values into the formula, we get:
30/50 x 1 = 0.6
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