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A nurse is contributing to the plan of care for an adolescent client.

Exhibits

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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Emergent (red tag) category includes patients with life-threatening injuries requiring immediate attention, such as a punctured femoral artery.
B. An open fracture may be urgent but not emergent unless associated with severe bleeding or other life-threatening complications.
C. Manifestations of multiple organ failure are severe but may fall into the expectant (black tag) category.
D. Closed fractures with bruising may be urgent but not emergent unless there are associated life-threatening complications.

A. Limit the number of health care workers entering the room. B. Insert an indwelling catheter to monitor for sediment in the urine. C. Take the client’s temperature once per shift D. Provide the client with fresh fruit to avoid constipation

Correct Answer is A

Explanation

A. Limiting the number of health care workers entering the room helps reduce the risk of exposure to infections.
B. Inserting an indwelling catheter is not a routine intervention for immunosuppressed clients and may increase the risk of infection.
C. Monitoring temperature more frequently than once per shift is crucial to detect early signs of infection in immunosuppressed clients.
D. Fresh fruit may carry a risk of bacterial contamination, and caution should be exercised in providing it to immunosuppressed clients.

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A nurse is contributing to the plan of care for an adolescent client. Exhibits Which of the following actions should the nurse identify as part of the plan of care? Select all that apply.

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A nurse is contributing to the plan of care for an adolescent client.

Exhibits

Which of the following actions should the nurse identify as part of the plan of care? Select all that apply.