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 {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}
Explanation
Understanding: A, D, E, F
No understanding: B, C
A. This indicates understanding. Distractions during meals are discouraged to focus on chewing and swallowing.
B. This indicates no understanding. This is not a recommended technique for managing dysphagia. It's important to maintain a neutral head position during swallowing.
C. This indicate no understanding. Nuts are a common choking hazard and are often restricted for individuals with dysphagia to prevent aspiration.
D. This is a correct understanding. It's important to separate drinking liquids and eating to prevent choking and aspiration.
E. This is a correct understanding. Depending on the severity of dysphagia, a soft or pureed diet may be recommended.
F. Cream soups are generally allowed on a dysphagia diet, as they are usually smooth and do not pose a high risk of aspiration.
Correct Answer is ["A","B","C","E"]
Explanation
A. This an example of a health care-associated infections (HAIs), which are infections that patients acquire during the course of receiving health care treatment for other conditions. The patient acquired the pneumonia after being in a ventilator.
B. This is an example of a HAI since the patient acquired the condition while receiving health care treatment for other conditions.
C. This is an example of a HAI since the patient acquired the condition while receiving health care treatment for other conditions.
D. This is not an example of a health care-associated infection (HAI), because it is not acquired during the course of receiving health care treatment. This is an example of a community-acquired infection, which is an infection that a person gets from contact with people or sources outside of a health care setting.
E. This is an example of a HAI since the patient acquired the condition while receiving health care treatment for other conditions.
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